ANNUAL REVIEW master Final3a - St Vincent's University Hospital

St. Vincent’s Healthcare Group Limited - Annual Review 2007
Reports
Department of Pathology & Laboratory Medicine
Service Developments/Activities
During 2007 there was a further major emphasis on quality initiatives and audit. Clinical Pathology
Accreditation UK Ltd. (CPA) carried out an inspection of the new facilities in conjunction with surveillance
audits in Biochemistry, Haematology, Blood Bank, Nuclear Medicine, Endocrinology, Metabolism and
Histopathology. The outcome of the visit was that Haematology/Blood Bank and Histopathology retained
their CPA accreditation and that the other laboratories listed above were granted full CPA accreditation status.
The Microbiology laboratory applied for CPA assessment in April 2007 and an assessment visit is scheduled
for March 2008.
In meeting the requirements of the EU Blood Directive, the Blood Bank applied for ISO15189 accreditation
in November 2007 with an assessment scheduled for January 2008.
In conjunction with ICT a major hardware upgrade of the laboratory information system was implemented in
September 2007, which resulted in a significant improvement in the operational performance of the system.
The laboratory quality management system Q-Pulse was upgraded to Version 5.0 in November and it is
planned to train all staff on the new system in 2008.
The level of achievement in the above projects could not have been achieved without the commitment and
team effort of all the Pathology staff.
Significant Developments
Other significant developments in 2007 include the following:
A programme to assist the management and usage of blood and blood products between St. Vincent’s
University Hospital and St. Michael’s Hospitals commenced in October. In 2005 a similar programme had
been set up with St. Columcilles Hospital, which was successful in improving the utilisation of blood.
The appointment of a blood bank network quality officer has facilitated the establishment of links between
the hospital blood banks in the region. In particular, the initiative has enabled SVUH blood bank to provide
support to the hospitals in the region in their efforts to achieve compliance with ISO15189 by the EU Blood
Directive deadline of November 2008.
Following the commissioning of new analysers and pre-analytical automation in the Biochemistry laboratory
in 2006, Roche Diagnostics have now identified the laboratory as the Irish “Showcase Site” for visitors.
There has been considerable expansion of the role of Biochemistry staff in the quality management of both
blood gas and glucose monitoring at point of care. The number of glucose meters and gas analysers has
increased and staff were involved in the validation of two new blood gas analysers for Theatre and the
training of over 100 Theatre nurses.
Testing for Her2 in-situ using a Fluorescence Hybridization technique was launched in Histopathology. The
test is used to determine treatment in breast cancer.
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