© Copyright, The Joint Commission Tracer Methodology Stacy Olea, MBA, MT(ASCP), FACHE Field Director use these colors

Delaware Valley Chapter CLMA Annual Fall Meeting © Copyright, The Joint Commission Tracer Methodology 101  Focus on issues of particular concern for laboratories and process interfaces with clinical staff. Consider those issues of particular concern to a laboratory, such as patient identification, quality control, and communication of critical test results. You can use these specific topics to plan a specialized tracer using a closed medical record.  Consider your laboratory’s past testing activity as a starting point. It can be very informative to conduct a tracer of past testing activity, particularly if a pattern of near-miss reports or quality control problems with a particular test have been observed.  Select the medical record of a patient who received multiple laboratory tests, including tests performed at point-of-care sites. This will help you look at multiple processes within your laboratory at one time. Follow the testing from the time of the order to the action taken, if indicated.

Delaware Valley Chapter CLMA Annual Fall Meeting © Copyright, The Joint Commission Tracer Methodology 101  Instead of one person conducting the tracer, consider walking through one as a group. Having an informal group discussion as you verbally “trace” through a closed medical record can help laboratory staff to better understand tracers. This is also a good opportunity to discuss possible “workarounds” or other potential problems that could result in a negative outcome.  Don’t forget to consider the beginning and end of a process, not just the outcome. For example, while tracking a specimen, make sure that you are following the work done by staff to both collect and then test that specimen. Observe work done with patients. Observe how patient identification is being performed. It is important to remember that tracers can be used to follow an entire process or system, and your goal should be to determine if there are any gaps or potential missteps.

Delaware Valley Chapter CLMA Annual Fall Meeting © Copyright, The Joint Commission Blood Administration The surveyor selected an 87 year old patient with anemia to trace, in order to review the entire transfusion process. The patient had been admitted with anoxia and anemia. The physician had ordered on admission laboratory studies, including a hemoglobin and a type and screen. When the laboratory reported the critical hemoglobin value of 6.8 gm/dL to the nurse, the nurse immediately called the physician, who then ordered a crossmatch for two units.

Delaware Valley Chapter CLMA Annual Fall Meeting © Copyright, The Joint Commission Blood Administration – Laboratory Manager  How does your laboratory obtain blood products?  What is the process to obtain blood in an emergency? Please provide an example.  Please provide your QC documentation for review.  How do you monitor the blood utilization and criteria for transfusion?  What backups are in place incase the refrigerator or freezer fails?  Please provide the temperature charts and alarm checks.  What is the process for patient identification during blood collection and throughout the transfusion?  Please provide the laboratory policies and procedures.  Please provide the competency file for the laboratory testing personnel.

Delaware Valley Chapter CLMA Annual Fall Meeting © Copyright, The Joint Commission Blood Administration – Transfusion Nurse  How is the patient identification retained on the unit throughout the transfusion?  How long can you wait before starting the transfusion?  Please provide the transfusion order and consent form.  How do you instruct the patient regarding transfusion reactions?  Please provide the blood transfusion policy and transfusion reaction policy.  When did you receive training on blood administration and transfusion reactions? Who can provide this documentation?

Delaware Valley Chapter CLMA Annual Fall Meeting © Copyright, The Joint Commission General Lab The surveyor selected a patient with a relatively long length of stay. The tracer started in the ICU. The patient was a 62 year old man admitted through the emergency department for chest pain. In the ED, physicians ordered a BMP, a cardiac panel, CBC, PT, APTT, and urinalysis. From the ED, the patient was immediately sent to cardiac catheterization, which was not successful. During the case, there were no ACTs performed. Blood gases were drawn and sent to the cardiopulmonary lab. The patient was sent to the ICU to prepare for a CABG. Once admitted to ICU the physicians ordered the general ICU admission profile (CBC, CMP, UA, MG, PHOS, UA, LDH, and cholesterol. Also, four units of fresh frozen plasma, six units of packed red blood cells, and two “super packs” of platelets were ordered.

Delaware Valley Chapter CLMA Annual Fall Meeting © Copyright, The Joint Commission General Lab – Laboratory Manager  What is your process to ensure continuity of communication and interaction between laboratory departments?  What participation do you have on organization wide committees?  Please provide competency documentation for the testing personnel.

Delaware Valley Chapter CLMA Annual Fall Meeting © Copyright, The Joint Commission General Lab – Lab Staff  Please provide your process for communicating and documenting a test result.  Describe your proficiency testing process.  How do you ensure safety in the lab?  How often do you do calibration verification?  Please provide me your correlations and QC documentation.

Delaware Valley Chapter CLMA Annual Fall Meeting © Copyright, The Joint Commission General Lab – Unit Staff  What is your process for ordering tests for a patient?  How do you communicate test results?

Delaware Valley Chapter CLMA Annual Fall Meeting © Copyright, The Joint Commission Questions