HospitalInspections.org

Based on review of clinical records and interview, it was determined three (#5, #20 and #21) of 45 patients underwent laboratory testing without a physician order. Failure to perform laboratory testing without a physician order did not assure patients did not undergo tests which were unnecessary or that the physician was aware of tests ordered without his knowledge. The failed practice was likely to affect all patients presenting to the Emergency Department. Findings follow:

A. Review of the clinical record for Patient #5 revealed laboratory results for PT (Prothrombin Time) and PTT (Partial Thromboplastin Time) but no evidence of a physician order for the test.

B. Review of the clinical record for Patient #20 revealed laboratory results for UA (urinalysis) and D-Dimer (test for blood clot) but no evidence of a physician order for the test.

C. Review of the clinical record for Patient #21 revealed laboratory results for Flu (Influenza) and Strep (Streptococcus) but no evidence of a physician order for the tests.

D. Findings listed as A-C were confirmed with the Director of Nursing on 02/13/15 at 1450.