D.10 Lab Information, 36C25522R0052.pdf

Pathology & Laboratory Medicine Service VA Medical Center, Columbia, MO https://dvagov.sharepoint.com/sites/vhacmo/clinical_support/lab/Lab General Information/LG-6a R5 General Information.docx Page 1 of 4

TITLE:

GENERAL INFORMATION

Prepared By Date Adopted/Replaces Approved By

Karen Kanuckel 01/17/2017replaces 10/24/2016

Edward H. Adelstein, Laboratory Director

Section Pathologist

REVIEW

Review or Revision

Date

Comments (check all that apply) Approved By

3/23/2011 No changes Revision initiated – see below Available on-line Edward Adelstein, M.D.

2/11/2013 No changes Revision initiated – see below Available on-line Edward Adelstein, M.D.

3/2/2015 No changes Revision initiated – see below Available on-line Edward Adelstein, M.D.

10/24/2016 No changes Revision initiated – see below Available on-line Edward Adelstein, M.D.

1/17/17 No changes Revision initiated – see below Available on-line Karen Kanuckel 5/11/18 No changes Revision initiated – see below Available on-line Susan Kitchen 10/29/20 No changes Revision initiated – see below Available on-line Krystal Tray

Date Page # Description of revision

3/23/2011 1 Added cover page and changed document name from LG-6a Web Site General Information to LG-6a General Information; phone number updates, contact when tests are delayed.

2/11/2013 1 Updated staff names and phone numbers

3/2/2015 2 R3, p.2 Updated staff names and phone numbers

10/24/2016 2 R4, p.2: Updated staff names and phone numbers

1/17/17 2 R5, p.2: updated staff names p.3: added statement about authorization for testing

5/11/18 3-4 Updated JPSR reporting; staffing names

10/29/20 2 Updated staffing names and phone numbers. Removed UH path call information.

Distribution

Clinical Lab Sections

Blood Bank Chemistry Morgue Hematology Immunology Microbiology Frozen Section

Lab Manager Pulm. Function SharePoint

Retirement Date Approved By Archived Location

D.10 Lab Information, 36C25522R0052 https://dvagov.sharepoint.com/sites/vhacmo/clinical_support/lab/Lab General Information/LG-6a R5 General Information.docx Page 2 of 4

GENERAL INFORMATION

Pathology and Laboratory Medicine Service (PALMS)

Edward H. Adelstein, M.D. - Director Pathology and Laboratory Medicine Service Telephone ext. 56451

Jared Coberly, M.D. – Staff Pathologist Telephone ext. 53007

Cynthia Mann – Program Support Assistant Telephone ext. 56450

Susan Kitchen – Lab Manager Telephone ext. 53025 Pager 5277

The VA Laboratory is staffed 24 hours / 7 days per week. Routine testing in Immunology is performed Monday-Friday 8am – 4:30pm. During regular work hours contact the responsible pathologist or supervisor for the laboratory section.

VA Laboratory Sections Section Supervisor Responsible

Pathologist

Blood Bank x53017 Marvin Twenter x53017 Dr. Coberly Chemistry x53030 Danae Bush x53019 Dr. Coberly Coagulation x53013 Kenneth Drewery x53016 Dr. Coberly Hematology x53015 Kenneth Drewery x53016 Dr. Coberly Immunology x53041 Marvin Twenter x53017 Dr. Coberly Microbiology x53021 Maria Gayo x53018 Dr. Coberly Point of Care Testing Trina Kimbrough x53034 Dr. Coberly Stacy Reed x53026 Dr. Adelstein Urinalysis x53014 Kenneth Drewery x53016 Dr. Coberly Morgue x53001 Susan Kitchen x53025 Dr. Adelstein Morgue Tech x53006 Outpatient Blood Draw Station x56453 Joe Chaumont x53009 Dr. Adelstein Lab Information Manager (LIM) IlahRae Wyatt x53010 Lab Quality Manager Krystal Tray x53039

A Senior Pathologist is on call during the evening, night and weekend shifts if problems arise that cannot be resolved by the laboratory personnel.

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UMC Phone Numbers

UMC Hospital Operator-----------------------7-2-4141

UMC Laboratory Sections UMC Anatomic Pathology office------------ 882-1221 UMC Blood Bank & Coagulation------------ 882-1296

UMC Bone Marrow---------------------------- 882-1285 UMC Chemistry--------------------------------- 882-1245

UMC Cytology----------------------------------- 882-1232 UMC Flow Cytometry-------------------------- 882-1330 UMC Electron Microscopy-------------------- 882-1255

UMC Hematology------------------------------- 882-1243 UMC Histology----------------------------------- 882-1224 UMC Immediate Response Processing---- 882-1242

UMC Toxicology--------------------------------- 882-1273

STAT Tests STAT turnaround time goal is one hour or less for most Stat requests.

Blood Gas turnaround time goal is 30 minutes – 15 minutes for Open Heart samples

Routine Tests Routine testing turnaround time is one (1) to four (4) hours, but certain tests may take up to eight (8) hours.

Scheduled (Batch) Testing – Some tests (e.g. Immunology) are performed on specified days. Other tests such as Microbiology may take several days to report.

Delayed Testing The lab will make every effort to notify clinicians of delays in testing and the expected reporting time. This is accomplished by notifying the clinic manager, service line manager or individual provider. A notice is sent to the Primary Care staff (vhacmopcsl) via Outlook stating the nature and expected duration of delay.

Authorization for Testing The lab may perform tests only at the written or electronic request of an authorized person. Unclear or questionable orders will be confirmed by contacting the ordering provider.

ADVERSE EVENTS – DEVICE RELATED & PHLEBOTOMY

1. Pathology adheres to the hospital Patient Safety Program HPM 589A4-079 regarding the reporting of device-related adverse patient events. Any incident that involves a patient must be reported using the hospital Joint Patient Safety Reporting (JSPR) form (located on hospital web page Patient Safety SharePoint) within 24 hours of the incident. The hospital safety officer will complete the required FDA forms with the assistance of the lab manager and/or lab supervisor.

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2. Any blood drawing incident that results in harm to the patient must be reported to the charge nurse or physician immediately. The Pathology staff member should also report the event to their supervisor or the lab manager immediately so that the appropriate information can be compiled for completion of the JPSR

Any adverse reaction in the outpatient blood drawing area (i.e. fainting, seizure, etc. SEE PHLEBOTOMY PROCEDURE 302) when necessary the Stat team or the code blue team will respond immediately. No JSPR form is required in this situation unless the situation involves a device-related injury or a patient injury or fall.

3. Device malfunctions or problems that are reportable may relate to any aspect of a test, including hardware, labeling (“labeling” refers to all user instructions provided by the manufacturer), reagents or calibration; or to user error (since the latter may be related to faulty instrument instructions or design). An adverse patient event that may have resulted from inherent limitations in an analytic system (e.g., limitations of sensitivity, specificity, accuracy, precision, etc.) is not reportable.