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Department of Microbiology
Quality Manual
Section: LIS Downtime and System Maintenance Subject Title: Downtime Procedures Department of
Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 17, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
1.0 PURPOSE.............................................................................................................................................3
2.0 INTRODUCTION...................................................................................................................................3
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 2 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
Department of Microbiology
UNIV ERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 3 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
1.0 Purpose
The purpose of the downtime policies and procedures manual is to ensure that during all types
of downtimes, the Microbiology Department remains functional, no data is lost and the
recovery procedures have minimal impact on the organization.
2.0 Introduction
A downtime is any period of time when a computer information system is not available. This
includes scheduled downtimes (planned downtimes for system maintenance and upgrades)
and unscheduled downtimes (due to hardware/software failures).
The information systems at Mount Sinai Hospital are highly integrated. Interfaces exist
between the Hospital Information Systems (HIS) which are Cerner and Mysis-EPR, the
Laboratory Information System, SCC and the MDI Solutions and Courtyard Group Ltd.
interface engines. Downtimes can occur within Cerner, Mysis-EPR, one of the departmental
systems, or the interface between them. Downtimes in any of these areas likely to affect other
areas and the impact must be considered. Each area should have sufficient workarounds to
ensure continuity of services during a downtime.
An accurate record of all information related to a patients care must be maintained at all times.
In the event that a system is not available, information will be recorded manually on designated
forms. When the system becomes available, information captured manually will be entered
into the system in the recovery phase to ensure the retention of complete and accurate
information.
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 4 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
Procedures. The intended audience for User Downtime Procedures includes departmental
managers, application specialists and system users.
4.0 Definitions
4.3 HP
Shared Information Management Services (SIMS) provides technical support for Mount Sinai
Hospital and the University Health Network (UHN).
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 5 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
Table 2
A B C D E F
Components HIS Healthlink HIS order HIS ADT HIS LIS
(Mysis- Interface entry (Cerner or results
EPR engine (Mysis- Mysis- reporting
Cerner or EPR, EPR) (Cerner,
Meditech) Cerner or Mysis-
Meditech) EPR or
Meditech)
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 6 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
5.1 Purpose
The purpose of the HIS downtime procedures is to ensure that orders from the HIS (Cerner,
Meditech or Mysis-EPR, ) continue to be processed and results from the LIS are sent out to the
facility whose HIS (Cerner, Meditech or Mysis-EPR) is down and no data is lost.
In the event of one or more of the HIS systems going down, the Microbiology Department will
continue to facilitate the entry of orders from the facility(s) into the LIS. Results will be phoned,
faxed, printed or hand delivered to the facility (MSH, UHN or Rouge Valley) where the HIS is
unavailable.
HIS is used
To send orders from the inpatient and outpatient wards from all of the facilities to the LIS.
Orders are placed in Cerner, Meditech or Mysis-EPR. For Mysis-EPR, the specimens are
ordered and sent to the Specimen Management Center (SMC) where they are
collected/accessioned. The act of accessioning sends an order to the LIS. The specimens
are sent from SMC to the Microbiology Department. For Cerner, the specimens are
ordered which sends an order to the LIS. When the specimen is collected, the collection
date and time is updated. Specimens are brought to the lab. For Meditech, the specimens
are ordered collected and sent to the labs at Rouge Valley. Once ready a batch
transmission is sent to the LIS and the specimens arrive by courier.
To send ADT transactions to the LIS as patients are admitted, discharged or transferred
within both MSH and UHN. ADT transactions are not received from Rouge Valley.
To send results from the LIS to the HIS (Cerner Meditech or Mysis-EPR)
A B C D E
Stage System Mysis-EPR HIS order Results
Time period order/acce no SMC reporting
ssioned by accessio
SMC or n or
Cerner and Cerner or
Meditech Meditech
order recd order not
received
1 Less than 1 hour AA1 AB1 AC1
2 After 1 hour AA1 AB2 AC1
UNIV ERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 7 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
5.5.1 AA Mysis-EPR order that has been accessioned by SMC. Cerner or Meditech
order that has been received.
AA1 For Mysis-EPR, the downtime occurred between accessioning by SMC and the arrival of
specimens in the microbiology lab. For Cerner, downtime occurred after the order was placed
but the specimen has not been received in the lab. For Meditech, the downtime occurred after
the batch transmission was sent but the specimen has not arrived by courier.
The specimens are received as usual in the LIS.
5.5.2 AB Mysis-EPR order that has not been accessioned by SMC. Meditech order that
was not transmitted. A stat Cerner order that must be ordered and collected
manually.
The Mysis-EPR downtime occurred between specimen collection and the arrival of the
specimens at SMC. The Meditech downtime occurred after the order was placed and
specimen collected but prior to the batch transmission for Meditech. A stat Cerner specimen
would be sent with a requisition.
AB1 Immediately
All un-accessioned specimens from Ulitcare are sent to the Microbiology Lab. The specimens
are held refrigerated for up to one hour. No other action is taken.
All non-transmitted specimens from Meditech are held by the facilities until the system is back
up. The stat Cerner specimen would be entered manually into the LIS and follow the
procedures under AB3.
1. Blood cultures: keep a list of specimens with patient name, MRN, HIS number and bottle
ID. Incubate off line in incubator. If the HIS is not back up, one hour before the lab closes,
load bottles in the Bact/Alert by scanning the bottle ID.
2. All other specimens: use the HIS specimen number for labeling plates and smears during
planting. Save the specimens in a separate basket for recovery.
3. Specimens that arrive with requisitions with complete patient information (MRN and visit #),
generate the order in the LIS.
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 8 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
4. Specimens that arrive with requisitions with incomplete patient information, use an internal
numbering system. Place the internal lab number on the requisition and plant the
specimens.
All specimens will arrive in the microbiology laboratory with requisitions. The patient
information on the requisition may be complete because the patient is already registered in the
HIS or incomplete because the patient has just been admitted and the HIS is down.
1. For those patients who are registered (MRN and visit #), generate the order in the LIS.
2. For those patients without a MRN and/or visit number, use an internal numbering system.
Place the internal lab number on the requisition and plant the specimens.
No change. Call Critical results and force print important results to fax, print or deliver at the
technologists discretion.
5.6.1 AA Mysis-EPR order accessioned by SMC, Cerner or Meditech order that has bee
received.
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 9 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
5.6.2 AB Mysis-EPR order that has not been accessioned by SMC. Meditech order that
was not transmitted and a stat Cerner order that must be ordered and collected
manually.
AB1 Immediately
Take specimens from storage, receive in LIS and plant as usual. Specimens will arrive from
Rouge valley and a batch transmission will have been sent.
1. For all specimens: accession the specimen in the HIS, receive the specimen in the LIS and
re-label plates, smears and blood culture bottles with the LIS order number.
2. Blood cultures: for bottles incubated off-line, label and load bottles as usual. For bottles
loaded by bottle ID, re-label bottle and use quick data entry in the Bact/Alert to attach the
order to the corresponding bottles.
3. For those specimens received with requisitions containing complete patient information, no
action is required.
4. For those specimens received with requisitions with incomplete information, generate an
order in the LIS and re-label plates.
1. For those specimens received with requisitions containing complete patient information, no
action is required.
2. For those specimens received with requisitions with incomplete information, generate an
order in the LIS and re-label plates.
Results will queue on the interface engine and as soon as the HIS is up, they will post to the
HIS.
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 10 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
6.1 Purpose
The purpose of the interface engine downtime procedures is to ensure that orders from the HIS
(Cerner, Meditech or Mysis-EPR) continue to be processed and results from the LIS are sent
out to the facility whose HIS (Cerner, Meditech or Mysis-EPR) is down and no data is lost.
In the event of the interface engine(s) going down, the Microbiology Department will continue
to facilitate the entry of orders from all facilities into the LIS. Results will be phoned, faxed,
printed or hand delivered to the facility (MSH, Rouge valley or UHN) when the interface engine
is down.
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 11 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
A B C D E
Stage System HIS Results
Time period orders reportin
g
BA1 Immediately
The specimens are ordered and accessioned in Cerner, Meditech or Mysis-EPR but no LIS
order is generated. Transactions are queued to the interface engine. No action is taken.
Specimens are stored appropriately.
1. Blood cultures: keep a list of specimens with patient name, MRN, HIS number (Meditech
and Mysis-EPR) or internal lab number (Cerner) and bottle ID. Incubate off line in incubator.
If the HIS is not back up, one hour before the lab closes, load bottles in the Bact/Alert by
scanning the bottle ID.
2. All other specimens: use the HIS specimen number (Mysis-EPR or Meditech) or an internal
lab number (Cerner) for labeling plates and smears during planting. Save the specimens in
a separate basket for recovery.
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 12 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
No change. Call Stat and critical results and force print important results to fax, print or deliver
at the technologists discretion.
BA1 No action required. As soon as the interface engine recovers, the order will be generated
in the LIS automatically.
BA2 Orders will still have queued and will be passed to the LIS as soon as the engine is back
up. The orders should be received in the LIS and the plates and smears re-labeled with the LIS
order numbers.
Results will queue to the interface engine and as soon as the engine is up, they will post to the
HIS
7.1 Purpose
The purpose of the order entry downtime procedures is to ensure that orders from the HIS
(Mysis-EPR, Cerner and Meditech) continue to be processed and no data is lost.
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 13 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
In the event of the order entry interface going down, the Microbiology Department will continue
to facilitate the entry of orders from all facilities into the LIS.
A B C D E
Stage System Order
Time period entry
1 Immediate CA1
2 After 1 hour CA2
3
4
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 14 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
CA1 Immediately
The specimens are ordered and accessioned in Mysis-EPR, ordered in Cerner or a batch
transmission is sent from Meditech but no LIS order is generated. Transactions are queued to
the interface engine. No action is taken. Specimens are stored appropriately.
1. Blood cultures: keep a list of specimens with patient name, MRN, HIS number (Meditech or
Mysis-EPR) internal number (Cerner) and bottle ID. Incubate off line in incubator. If the HIS
is not back up, one hour before the lab closes, load bottles in the Bact/Alert by scanning
the bottle ID.
2. All other specimens: use the HIS specimen number (Meditech or Mysis-EPR) or the
internal lab number (Cerner) for labeling plates and smears during planting. Save the
specimens in a separate basket for recovery.
CA1 No action required. As soon as the interface is back up, the orders will be generated in the
LIS automatically.
CA2 Orders will still have queued and will be passed to the LIS as soon as the interface is
back up. The orders should be received in the LIS and the plates and smears re-labeled with
the LIS order numbers.
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 15 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
8.1 Purpose
The purpose of the HIS admission, discharge and transfer (ADT) interface downtime procedure
is to ensure that updates from the HIS (Mysis-EPR at UHN and Person Management at MSH)
continue to be processed when the interface is down and no data is lost.
In the event of the HIS ADT interface going down, the Microbiology Department will continue to
facilitate the entry of orders from UHN and MSH into the LIS.
A B C D E
Stage System ADT
Time period
1 Immediate DA1
2 After 1 hour DA2
3
4
DA1 Immediately
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 16 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
DA1 Immediately
For UHN: No action required. As soon as the interface is back up, the ADT transactions and
the orders will be generated in the LIS automatically.
For UHN: ADT transactions and orders will still have queued and will be passed to the LIS as
soon as the interface is back up. The orders should be received in the LIS and the plates and
smears re-labeled with the LIS order numbers.
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 17 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
9.1 Purpose
The purpose of the results reporting interface downtime procedures is to ensure that results
from the LIS are sent out to the facility whose HIS (Cerner, Meditech or Mysis-EPR) is down
and no data is lost.
In the event of the results reporting interface going down, the Microbiology Department will
continue to ensure that results willl be phoned, faxed, printed or hand delivered to the
appropriate facility (MSH, Rouge valley or UHN).
A B C D E
Stage System Order
Time period entry
1 Immediate EA1
2 After 24 hour EA2
3
4
EA1 Immediate
No change. Call Stat and critical results and force print important results to fax, print or deliver
at the technologists discretion.
UNIV ERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 18 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
Results will queue to the interface and as soon as it is up, they will post to the HIS.
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 19 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
10.1 Purpose
The purpose of the LIS downtime procedures is to ensure laboratory orders from MSH, Rouge
valley and UHN are processed in a timely manner and that results from the LIS are sent out to
MSH and UHN while the LIS is down and no data is lost.
In the event of the LIS going down, the Microbiology Department will continue to ensure that
orders will be processed and Stats and critical results are phoned to the appropriate facility
(MSH, Rouge valley or UHN).
A B C D E
Stage System Order Results
Time period entry reportin
g
1 Immediate FA1 FB1
2 After 1 hour FA2 FB2
3 After 5 hours FA3 FB3
4
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 20 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
FA1 Immediately
No action is taken. Store all specimens appropriately. Continue with all processes that do not
require the use of the LIS.
1. For specimens with an Mysis-EPR or Meditech number, use the HIS specimen number to
label the plates and smears. Save the specimens in a separate basket for recovery. For
Cerner orders with an LIS number, process as usual.
2. For specimens received with a requisition, use an internal lab number. Label the
requisition, plates and smears with the internal number.
3. During the downtime, the LIS officer will be in frequent communication with the LIS vendor.
As the downtime approaches 5 hours, a decision will be made to switch to the auxiliary
system after approximately 5 hours of downtime.
1. Specimens already planted using the Mysis-EPR or Meditech number will now have orders
generated in the LIS. These orders will need to be received and plates and smears
relabeled with the LIS labels.
2. Specimens received with a requisition, can be reordered in the LIS and the requisition,
plates and smears relabeled with the LIS numbers.
3. All new orders can be processed as usual.
4. Once the main system is fixed, there will be another period of downtime while all
transactions on the auxiliary system are passed back to the main system for catch up.
During this shorter period of downtime, procedures 1 and 2 from FA2 will have to be
instituted again.
FB1 Immediately
No action is taken. All Stats and critical results are phoned and documented.
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 21 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
1. All technologists will be issued blank requisitions which will be numbered from the plates as
they are read.
2. All observations and test results will be written on the backs of the requistions.
3. All Stats and critical results will be phoned and documented.
1. Once the auxiliary system is functioning, all results can be entered into the LIS.
2. The results documented on requisitions will have to be re-entered into the LIS.
3. Results that file back to the HIS(S) will be automatically sent out.
4. The LIS officer(s) will manually print other print runs for distribution of reports to the wards.
5. During the switch back to the main system, all necessary observations, test results and
phoned results will need to be recorded again on paper.
FA1 Immediate
No action required
1. All specimens from Mysis-EPR and Meditech that have not been received in the LIS from
the main downtime and all from the downtime for the switch back to the main box will have
to be received in the LIS and the plates and smears re-labeled.
2. All specimens received on requisitions that have not had orders generated in the LIS from
the main downtime and all from the downtime for the switch back to the main box will need
orders generated in the LIS and the plates and smears re-labeled.
FB1 Immediate
No action required.
UNIV ERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
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TML/MSH Department of Microbiology Quality Policy QIMMI04011.03 Page 22 of 22
Manual
Section: LIS Downtime and System Subject Title: Downtime Procedures Department of
Maintenance Microbiology
Prepared by: LIS Committee Original Date: October 22, 2008
Issued by: Laboratory Information System Revision Date: June 15, 2010
Approved by: Laboratory Director Annual Review Date: May 31, 2013
1. All observations and test results that have not been re-entered into the LIS must be
completed.
2. All results will have queued up and will be transmitted automatically to the HIS.
3. The LIS officers will follow up on any outstanding print runs and manually print the reports
for distribution.
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use
/conversion/tmp/scratch/365875881.doc