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SUBJECT: CANCELLING DUPLICATE LABORATORY TESTS

POLICY: This policy is to prevent possible duplicate drawing, testing, and double billing of laboratory tests ordered in Epic. This policy is to insure effective coordination of inpatient and emergency room laboratory orders submitted electronically by multiple care givers.

This policy is to ensure the cancelling, adding test on to blood in lab and merging of accession numbers is done consistently throughout all departments of the laboratory.

The LIS is set up to take care of some duplicate testing if ordered within a certain time frame of each other. When duplicate testing falls outside of the LIS time frame parameters, then manual cancelling will be done by the laboratory personnel.

PROCEDURE:

Department: Dispatch/HUB

Third shift dispatch/HUB: For morning run: Dispatch will view orders in ADHOC, and cancel duplicate orders. They will place in the order comment (canned comment), Duplicate with entire accession number _ _ _ _ _ _ _ . Dispatch will also merge routine morning lab orders within a four hour period of any timed test, such as; H &H’s, Glucose’s, APTT’s, Troponins and all other TDMs.

Dispatch all shifts/HUB: All single orders are then checked for blood in the lab. Add-ons should be added to the blood in lab that was drawn within 2 hours of the add-on or longer if specimen is stable. In the order comment, dispatch/Hub staff will verify collection from the blood in lab. In the comment section they will put “blood in lab” along with the accession number of blood in lab and print label to specimen processing printer #SP3. It is then up to the techs and or specimen processing to add this test to accession number of blood in lab, or pass the addon label to chemistry tech, to locate and run the addon tests with the new accession number. Whoever does this will document that the tests were added to the blood in lab.

The employee working dispatch/Hub will also check timed orders such as TROP and APTT’s which are usually ordered every six hours. Dispatch/Hub personnel will correct timed frequency to every six hours x3, when tests are ordered for more than 3 times. Review orders in EPIC prior to contacting the nursing staff. STATS will be collected as ordered. Draw any routine labs within a 4 hour window of all stats.

Dispatch, data and or techs/HUB: Personnel will also merge ‘like’ departmental tests onto the same accession numbers. Examples; PT and APTT paying close attention to the timed APTT order. In other words, you can merge the PT to the timed APTT order, but not the other way around.

BMP, MG, Heppa, TROP, any chemistry with a 97 extender, or PST tube label, can be merged paying close attention to the timed test. Always merge to the timed test. Example, merge the BMP to the timed TROP. Always document “added tests to accession number _ _ _ _ _ _ _”. These merges should take place PRIOR to receiving the specimen in data.

When a PLT is ordered along with a CBC or CBCWO on separate accessions, then merging these tests should cancel out the PLT as a duplicate. Likewise, when a CBCWO is ordered on separate accessions to a CBC, the CBCWO should be cancelled. When HH is ordered with a CBC or CBCWO, the HH is a duplicate test.

It is important to always document in order comment when a test is cancelled and added to an existing accession.

(For physicians) Routine testing will not be drawn between midnight and 0400am. Routine testing will be drawn with morning run or during daily rounds throughout the day. Only STAT and Timed tests will be drawn between these hours.

The LIS will not merge Lytes to a BMP or a BMP to a CMP, this is something the tech, data, or dispatch/HUB staff will have to take care of. Once again, remember to document in the order comments.

Line draws: If a patient has tests ordered as a lab collect but is actually a line draw, and the RN hasn’t collected these within 4 hours of the ordered time, these tests should be changed to routine with the comment, ‘line draw 4 hours old’.

Post day blood draw duplicates: These orders can be cancelled as not collected or duplicate test after 8 hours of no specimen receipt. These too will be documented as not collected.

Techs only: Only the techs will be able to cancel duplicate urinalysis orders after investigating the urine department’s incomplete list. These orders will also be documented in the order comments ‘duplicate with accession _ _ _ _ _ _ _ _’ .

UA’s ordered as collected from ED can be cancelled after 4 hours if not collected.

Cultures ordered in ED and not collected before patient discharge can also be cancelled as ‘not collected.’

Techs will also investigate duplicate urine culture orders. If a patient has had a culture ordered and plated within (8) hours, call the RN and confirm order for additional urine culture. Document this call and cancel if it is found to be a duplicate.