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May 2005
Originally published in CAP TODAY
Desiree A. Carlson, MD, Editor, Laboratory Accreditation News
Are laboratory procedures written so that you can show the inspector that for every test there's an external PT program or an alternative program?
Are all PT samples handled in the same manner as patient samples as
far as possible?
PT samples are supposed to be handled the same way as real patient samples
as much as possible. "But it's the 'as much as possible' area that needs more
thought," Dr. Hoeltge says. "It's never going to be exactly like a real patient
sample, but to the extent you can incorporate it into your regular workflow,
you should. That means if sometimes you do this particular test at night and
on weekends, or with people who are not very experienced, you also ought to
do PT at night and on weekends and have people without much experience reporting
out PT data."
Does the lab use an alternative PT testing system to determine the
reliability of testing when no external program is offered, at least semiannually?
Does the laboratory have a procedure for assessing performance on PT
challenges or reasons why an event was not graded?
"Maybe it was lack of consensus, or maybe the laboratory submitted results
after the cutoff date or didn't submit them at all. Or maybe it had an inappropriate
method code and the computer couldn't handle it. Some of these will result in
'unacceptable' or 'unsatisfactory' scores," Dr. Hoeltge notes, "but all require
documentation review and corrective action if that review so directs."
Has the laboratory director or designee documented the level of PT
assessment schemes, and is there evidence of corrected problems?
"The CAP inspector on site may not ask these questions in so many words, but
you can be sure he or she is thinking about them. So ask yourself the same questions
and think, 'Did that PT evaluation I just signed off on provide me with an opportunity
for improvement?'"
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