Process for Correcting Misassigned POCT Results

CLIA requires laboratory results corrections to be performed in a manner that does not delete the original lab results because they may have been already seen (and acted on) by a provider. So, the results are documented as edited in the EMR (don't delete them). Wrong results in the wrong patient's EMR should have documentation that the provider was notified of the correct results somewhere in the EMR (we use "Notes" in EPIC). We developed written procedures for corrections. The Operator also submits an "incident" ticket with our LIS and a SAFE event ticket because this is a patient safety concern since wrong results on the wrong patient can lead to misdiagnosis and mistreatment. CAP has specific checklist items for this too. Remedial education and interfacing are how we mitigate these errors.

Our policy is to remove the whole record when a wrong patient was scanned even if the person running the test swears that the correct person is the other person. I was once at a place that allowed us to change the patient record to be assigned to another person but my lab director at the time asked a really good question - how are you sure that the person saying that it is this particular patient remembers correctly; so out of precaution, we removed the results. 

In that situation, the point of care department removes the results. The edits are documented in epic where it says it was edited and it can be traced back to the original record. We inform the provider and we document that information also. 

We file a safety event so we can document the issue and find the root cause of the issue. It comes back to education. When I train, I always inform them to bring the device into the room. Some nurses take the sample outside the room and test it away from the patient, scanning a piece of paper with the patient's record number.

All your actions should be documented, inspectors will ask about these things, they have with me.

Like you, we have Epic and RALS as well. The POC coordinators in the lab correct erroneous results in Epic (Beaker) with a corrected report and document the notification in the comm log. This way, the original erroneous results are still present and traceable.  

We also have EPIC but interfaced with UniPOC.  The POC Team performs all corrections in both the Beaker Workflow and the Ambulatory (Enter/Edit) workflow.  We will not "resend" results of a patient to a different patient's chart, as it is basically taking someone's word regarding patient Identification.  We have written procedures for both Beaker and Enter/Edit workflows and are entering a "This value is erroneous, please ignore" statement in place of the erroneously reported result.  An Event Report is also generated in our Pulse Power system so these events are tracked.  We also enter this into a spreadsheet used for non-conforming events.  (We have involved in both CAP inspections and TJC inspections for POC testing at multiple locations.)  All changes are traceable and are audited during survey preparation to be sure of that.   

We use Epic and Telcor,  using Rawls would not impact this solution however:

We created a SharePoint form that can be found on the intranet system webpage *AND* it is also linked to the top of the Epic toolbar for all clinical staff for easy access.  When the sharepoint form: "POC Corrections Form" is submitted it automatically generates an email to a shared email group: "POCReview".  The email subject title contains the specific facility the incident occured at so that facilities POC team can address it.  This POC Correction form is used to make the nessesary corrections, all corrections must be submitted this way.  Once these emails have been addressed they get dragged into the "completed" subfolders within the email group for future reference.

Who is responsible for correcting the result (e.g. POCT team, laboratory, HIM, IT)?

     How is the audit trail maintained?

     Are there specific policies or workflows you can share?

     Have you implemented any safeguards to prevent recurrence?