QJULI

My pathologist is not a hospital employee. . .so they have to go through the upper levels of hospital administration also. My pathologist knows I have followed the chain of command and notified my upper levels also. I have not had any news but remain hopeful that the wheels are in motion to have productive outcomes to the situation. By being 'with' me I mean that the pathologist is not comfortable and does not accept the lack of disciplinary action to the employee and is not happy that they received no notification of the questionable activities. .. . and that when specifically questioned the lab manager initially denied that there was more than my complaint. Pathologists aren't too happy when things that affect their medical license are swept under the rug. . .. . . is how I interpret it. Thanks for the continued support.

I did check and research extensively the 'legal' issue. No definitive answer from anyone. Is it forging a record? Is it simply unethical to write down a QC result that you didn't really do? If no patient work was involved. . .is it just an issue for the accrediting body? CAP doesnt' agree with JCAHO doesn't agree with AABB. If you have definitive resources I would love if you could share. Thanks. . .

I have proven on two occassions that the employee did not and could not do the work. . .did not use the materials and did not have the reagents to get the results he recorded. In the past few days I have contacted my hospital CEO. He is the direct boss of my lab manager. I can't trust my lab manager, so after much thinking I decided I had to inform and put my trust in the CEO. He has a right to know of the behavior happening in the hospital he leads. I have maintained contact with my pathologist and I have his full support. Just yesterday another section supervisor handed his evidence of 'dry labbing' by the same employee to the lab manager. This supervisor was told that despite previous conversations about the topic, there was no formal documentation, and the lab manager was going to work on some sort of monitoring. Another free pass to my point of view. I continue to be appalled. I have made efforts to protect myself. Two trusted friends outside the lab have copies of all my documentation, letters, emails etc. There are a few other work opportunities in my area and I have already researched one because I see quite clearly that I might not be able to stay where I am. I am fortunate that I don't HAVE to work. I enjoy work, I would have to change some things in my lifestyle, but it would not hinder the future of my children etc. if I was unemployed for a year or so. I am not going to give up on the situation. I must continue to have faith that the 'right' thing will be done. I don't have time to wait . . .if everybody eventually gets what they deserve. . .because it could be my family, my friend. . .going to my hospital tomorrow. Thanks again for all your support. Accrediting agencies can't come in and fix this. It's got to work from the inside. . .. so I stay. And I do the right thing, set the right example, provide quality results and do my best to ensure patient safety in my work and the work of people that DO follow my example. That's what I do. I'm not perfect. . .but I'm not going to walk away.

Well it only got worse!! My lab manager threw me under the bus. He denied any previous knowledge or accusations against the 'dry' employee to the pathologist and made me look like a vindictive, troublemaker. I did manage to set the record straight with the pathologist who is not stupid, knows he was lied to, and is not happy. SO. . .now do I go to hospital administration and tell them that PATIENT SAFETY is not at the top of the list in the laboratory?? Isn't my lab manager, who lied to protect the 'dry' employee JUST AS GUILTY as the employee who was actually fudging the records?? Nothing FDA reportable, nothing left the lab. . .this time. Still working on CLIA and JCAHO angle. I don't want to lose my job. I am safety minded!! This is a horrible stressful situation. IF I go to hospital administration and it all comes out with my boss. . .. how much more miserable will my job be?? I just keep weighing my choices and looking for guidance and suggestions. Thanks for all the posts!!

I have recently proven for the second time that an employee is 'dry lab' testing blood bank reagent QC. The second time also proved that he was not performing the unit retype either. My direct supervisor did not (to my knowledge) discipline this employee. IF he had a written warning the first time I guess I thought he would have been suspended or fired on the second offense. That has not happened. Does anyone have any suggestions on what to do? I have tried to contact my pathologist to see if he is fully aware. I have sent emails to the accrediting agencies to see if forging this record is illegal or just unethical. I am not getting communication back and I am really struggling. Thanks for all your suggestions.

It was my understanding that the FDA believes that a 'hospital' is a monitored environment, and that units should stay within the 1-6 temp range. . .. not the 1-10 that we used to always accept. How then can you allow nursing to return a unit for up to 30 minutes and remain in the 1-6 range?? I did a study and found that in 7 to 10 minutes at room temp, the units were above 6 degrees. I changed SOP to reflect this over 2 years ago and nursing now has only 10 minutes to return a unit. What are others doing???

I have a position information questionnaire (human resources pay scale setting tool) for a QA Coordinator position that was strictly in the blood bank. I also have a brief job description. I am comfortable sharing this becuase when I left the postion, it was not rehired/refilled to these definitions. I could fax if you send me a number. Please email jquast@deltahospital.org. Thanks

When we do the computer entry AFTER a downtime, we use the generic computer user ID of DOWNTIME. This signals any one looking at the record that is a COPY of the results and has been entered into the computer from a paper record.

I would like to add that your reagents may have a limit as to the age of the specimen. . you should be checking your package inserts to see how old the specimen can be.

We will use the specimen RESULTS for greater than 3 days IF the patient has signed a statement that they have not been pregnant and have not been transfused in previous 3 months. We have to PERFORM the testing within 24 hours of collection. This question/poll seems a little misleading. . .what exactly were you trying to determine??