CAP Laboratory Accreditation Program Requirements

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CAP Laboratory Accreditation Program Requirements

GEN 20208

  • There must be an organized program for the documentation of problems involving the laboratory that are identified internally, as well as those identified through outside sources such as complaints from patients, physicians or nurses.
  • The program must be implemented in all sections of the laboratory, and on all shifts.
  • Any problem that could potentially interfere with patient care or safety must be addressed.
  • Laboratories must perform root cause analysis of any unexpected event involving death or serious physical or psychological injury, or risk thereof (including "near misses" and sentinel events).
  • Laboratories must be able to demonstrate appropriate risk-reduction activities based on such root cause analysis.