Waived Testing patient test log
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We have an ED that performs hundreds of UPG tests each month. The UPG kits are QC'd appropriately and each cassette must be retrieved from a PYXIS. We feel somewhat confident that each test is being ordered and resulted in the patients EMR, minus a cassette lot number.
Using JCAHO WT 05.01.01, are we in compliance without a cassette lot number trace?
Have you ever been cited for not having a patient log in similar cases?
Thank you,
Erika Deaton-Mohney MT(ASCP), POCC
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There is specific mention in the standard of being able to associate patient results with the relevant Quality Control (internal or external) for period during which the patient was tested, but I don't see specific wording for test cartridge lot numbers. If you have a centralized means of knowing what cartridge lot numbers you have in use (like an inventory log) so that you could retract any recalled product should that need arise - I would think you are covered.
We capture lot#s, either through RALS or on a maual form