Healthcare Inspection – Point of Care Testing Program Concerns, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio

OIG conducted an inspection in response to complaints about lapses in policy compliance and quality oversight for the point of care testing program by Pathology and Laboratory Management Service at the Louis Stokes Cleveland VA Medical Center (facility), Cleveland, OH. A complainant alleged that some facility staff members improperly shared point of care operator identification barcodes with those who had not been issued identification barcodes or whose identification barcodes had lapsed due to lack of training. The complainant also alleged that some patient point of care laboratory values could not be linked to the correct patient’s electronic health record because operators entered incorrect patient identifiers, that management failed to track misuse of operator identifications and incorrect patient identifiers, including unresolved errors, and that testing operators were not trained in accordance with facility policy. We substantiated the allegations that some staff shared test operator identifications and improperly entered patient identifiers. We did not substantiate the allegation that management failed to track misuse of operator identifiers and incorrect patient identifiers including unresolved errors. The facility had a process established to track missing or incorrect patient identifiers; however, we found that managers did not consistently track errors to resolution. We substantiated that staff not trained in accordance with facility policy and procedure were performing tests, and we found weaknesses in the training and competency assessment process, which may have been a contributing factor. We made four recommendations.