LAB Rules
Can you have food/drink in the lab
Eating, drinking, smoking, applying cosmetics or lip balm and handling contact
lenses is prohibited in work areas where there is potential for exposure to blood
borne pathogens.
What must you do when you open a new box of HIV or pregnancy tests
Perform control tests and document on QA logs
Where do we need to put the ER cart at the end of the night
In the locked storage room
Do you need to offer everyone a receipt
Yes
What are the situations by law, that require us to break confidentiality?
Court Order, STI's Reporting to Health Department, Express harm self or others.
Required reporting for Minors- When abuse/neglect is suspected, sexual coercion, refusal to get care for life threatening condition
Reference: Limits of Confidentiality
What would you do if the refrigerator temperature is out of range
Document the out of range temperature. Recheck temperature. Contact Meggan Leary
What do you need to write on a sterile pack of equipment
Date instruments was packaged, Autoclave number (if site has more than one), and staff initials.
Reference: Health & Safety Manual - Chapter 6 Cleaning, Disinfection and Sterilization
When do sharps containers need to be changed
When they reach the fill line (approx. 2/3 full)
Can we email patients test results
Yes, if the patient has consented (signed) "Consent For Electronic Communication. Email can be used as a notification attempt for abnormal results.
(will soon be phased out due to the availability of the MyChart patient portal.)
Where are patients paper charts and is there a way to retrieve them?
o Bonus point if they know how many years they are stored
Iron Mountain Storage
Yes, work with CM to retrieve them
7 years
What should you do to your computer if you are walking away from it or going to lunch
Log out- restrict access to patients and peers to use your log in
What would you do if spore testing failed
1. Immediately check the autoclave for proper use and function and repeat the spore
test. A single positive spore test result probably does not indicate sterilizer malfunction. Objects do not need to be re-sterilized because of a single positive spore test
unless the sterilizer or the sterilization process is found defective. Sterilizer should be
removed from service and sterilization operating procedures reviewed to determine
whether operator error could be responsible.
2. All sterilization indicator strips must continue to turn the appropriate color.
3. If a spore test remains positive:
• discontinue use of the autoclave
• immediately notify supervisor
• remove all sterilized packs from inventory dated after the last negative
spore test result
• use alternative equipment (e.g. disposable speculum)
• call for service
When repair is completed, rerun biological spore test prior to sterilizing equipment for use.
What items need to be put in a biohazard bag instead of the garbage
Discarded blood, products of blood and anything caked, soaked or dripping with
blood.
Do you need to offer everyone notice of privacy practice
YES
When do you need to give out an IPV card
At the least annually during the following visits:
Preventive Care, Postpartum, Contraceptive and EC visits (excluding Pick-up and Injection-only visits.)
Abortion Visit, STI/HIV testing, GAHT and/or new partner reported and Red Flags for abuse.
Reference: PPWI MS&G Chapter 12:IPV
What do we do with a multi- dose vial that has been opened
Vials must be discarded if there is evidence of contamination.If a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial must be dated and discarded in accordance with manufacturer’s instructions and state/local regulations. If no specific guidelines are provided, CDC recommends discarding the vial within 28 days
Where can you find the most current STI treatment guidelines
CDC website
Sharepoint
What needs to happen after we use the ER cart
Licensed staff must complete the "Recheck after use" section of the Emergency Cart Inventory and reorder supplies, as indicated.
How do we track EC OTC
There is a workflow staff will follow called OTC EC Sales found on SharePoint.
What do you do with expired/ recalled medication
Expired meds- Adjust off the inventory and place in the pharmaceutical waste bin. Controlled substances have additional requirements.
Resource: Waste Disposal Guides 12 20 2023
Recalls- Management depends on the class of recall. Notify Meggan Leary if you receive a recall notice.
Resources: PPWI Medical Standards & Guidelines Admin Chapter 7 Pharmaceuticals
Describe your process for packing up specimens (how do you know what you are sending out)
Refer to the Collecting and Shipping Lab Specimens Competency 04.02.2025 and the LabCorp Packaging and Shipping Procedure on SharePoint.
How does PPWI track inventory for medications/BCM
For take home meds we dispense: Willow Inventory in EPIC.
For CAM's - Business Operations uses EPIC reports to manually decrement inventory for meds administered in clinic.
Is there a process in place to ensure that all the testing we send out is resulted in EHR
CFU and Informatics' RN run reports weekly that identify labs without results, work in tandem with CFU to follow up with patients.
What do you need to do if you take a call from a patient who has medical questions
Document the incoming call in a Telephone Call encounter and route it to the CFU RN Pool.
Describe your process for dispensing & labeling medication
The label must also include the following information, which may be added by hand at the time of dispensing:
A. Date of the prescription
B. Name of the patient
C. Directions for use including frequency and route of administration
D. Name of the prescriber
E. Number of refills, if applicable