Schedule of Accreditation
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1 Schedule of Accreditation Organisation Name Bon Secours Hospital Tralee INAB Reg No 206MT Contact Name Cara Wrenn Address Strand Street, Tralee, Kerry Contact Phone No Website Accreditation Standard ISO Date Initially Awarded 09/12/2008 Scope Classification Scope Classification Scope Classification Microbiology and virology Blood Transfusion Science Histopathology and cytopathology Services available to the public¹ ¹ Refer to document on interpreting INAB Scopes of Accreditation Sites from which accredited services are delivered (the detail of the accredited services delivered at each site are on the Scope of Accreditation) Name Address 1 Head Office Strand Street, Tralee, Kerry, W92 P663 INAB Registration No. 206MT Page 1 of 8 Edition 1, 12/06/2018
2 INAB Registration No. 206MT Page 2 of 8 Edition 1, 12/06/2018
3 Scope of Accreditation Head Office Blood Transfusion Science Category: A Medical pathology field - Test science -.01 Blood grouping including ABO, Rh(D) and other antigens by manual methods science -.03 Blood group antibody screen science -.04 Identification of blood group antibodies science -.05 Cross match compatible donor units science -.06 Red cell phenotyping science -.09 Direct antiglobulin test Test/assay Specimen Type Equipment/Technique Method (CE/Non- CE/In house developed/based on standard method) Blood Grouping (ABO & RhD Typing). Antibody Screening. Antibody Identification Red blood cells. Plasma Crossmatch testing Plasma/red blood cells Crossmatch testing Antigen typing Direct Coombs testing Plasma/red blood cells Red blood cells Red blood cells Antigen Typing Red Blood Cells Direct Coombs Test Range of measurement Std. ref & SOP INAB Registration No. 206MT Page 3 of 8 Edition 1, 12/06/2018
4 Head Office Histopathology and Cytopathology Category: A Medical pathology field - Test 1051 Histopathology -.01 Processing fixed specimens for Histopathological testing Test/assay Cut up Tissue Processing Embedding Microtomy Haemotoxylin/Eosin Staining Mounting (Coverslipping) Special Stains: Alcian Blue Congo Red Combined Alcian Blue PAS Millers Elastic Gram Stain Van Gieson Masson Fontana Trichrome PAS PAS Diastase Perls Prussian Blue Toludine Blue Ziehl Neelson Modified Giemsa Specimen Type Equipment/Technique Method (CE/Non- CE/In house developed/based on standard method) Range of measurement Std. ref & SOP Human Tissue Automated & Manual BST/HIS/SOP/029 BST/HIS/SOP/030 BST/HIS/SOP/002 BST/HIS/SOP/003 BST/HIS/SOP/004 BST/HIS/SOP/005 BST/HIS/SOP/006 BST/HIS/SOP/035 BST/HIS/SOP/036 BST/HIS/SOP/037 BST/HIS/SOP/038 BST/HIS/SOP/039 BST/HIS/SOP/043 BST/HIS/SOP/044 Automated & Manual BST/HIS/SOP/029 BST/HIS/SOP/030 BST/HIS/SOP/002 BST/HIS/SOP/003 BST/HIS/SOP/004 BST/HIS/SOP/005 BST/HIS/SOP/006 BST/HIS/SOP/035 BST/HIS/SOP/036 BST/HIS/SOP/037 BST/HIS/SOP/038 BST/HIS/SOP/039 BST/HIS/SOP/043 BST/HIS/SOP/044 Automated & Manual BST/HIS/SOP/011 Automated & Manual BST/HIS/SOP/ Histopathology -.04 Histological interpretation-medical renal pathology Diagnostic Interpretation & reporting of human tissue specimens Manual BST/HIS/SOP/010 BST/HIS/SOP/030 BST/HIS/SOP/031 BST/HIS/SOP/033 BST/HIS/SOP/034 INAB Registration No. 206MT Page 4 of 8 Edition 1, 12/06/2018
5 Specilist areas excluded: Medical renal pathology Paediatric Pathology Perinatal Pathology Neuropathology Breast screening pathology BST/HIS/SOP/035 BST/HIS/SOP/036 BST/HIS/SOP/037 BST/HIS/SOP/038 BST/HIS/SOP/039 BST/HIS/SOP/040 BST/HIS/SOP/044 BST/HIS/SOP/007 Manual BST/HIS/SOP/010 BST/HIS/SOP/030 BST/HIS/SOP/031 BST/HIS/SOP/033 BST/HIS/SOP/034 BST/HIS/SOP/035 BST/HIS/SOP/036 BST/HIS/SOP/037 BST/HIS/SOP/038 BST/HIS/SOP/039 BST/HIS/SOP/040 BST/HIS/SOP/044 BST/HIS/SOP/ Histopathology -.05 Histological interpretation-paediatric pathology 34 BetaE12 AE1AE3 AMACR (P504S) BCL-2 BerER4 Ca125 Cam 5.2 CD5 CD10 CD79a CD20 CD30 CD3 CD34 CD56 CEA CD45 Cytokeratin 5/6 Cytokeratin 20 Cytokeratin 7 Chromagranin A Desmin EMA HMB45 KI-67 (MIB-1) Melan A PSA P63 S100 Smooth Muscle Actin TTF-1 Vimentin Automated & Manual BST/HIS/SOP/013 BST/HIS/SOP/026 Automated & Manual BST/HIS/SOP/013 BST/HIS/SOP/ Cytopathology -.02 Non gynaecological cytology Gross description, processing & staining of bodily fluids & aspirates. Stained cytology slide (PAP & MGG) Microscopic examination human Tissue or fluid automated & Manual BST/HIS/SOP/010 BST/HIS/SOP/017 INAB Registration No. 206MT Page 5 of 8 Edition 1, 12/06/2018
6 Frozen Sections automated & Manual BST/HIS/SOP/010 BST/HIS/SOP/017 INAB Registration No. 206MT Page 6 of 8 Edition 1, 12/06/2018
7 Head Office Microbiology and Virology Category: A Medical pathology field - Test 1012 Preparation of films on glass slides followed by microscopic examination with or without fixation and staining with dyes as required -.01 Microscopic examination for general bacteriology purposes (including enumeration and description of human cells) 1013 Culture of organisms in liquid or agar based culture media with visual or instrument monitoring for growth -.01 Culture of general bacteria 1016 Identification of cultured bacteria and fungi using non-nucleic acid based techniques -.01 Biochemical methods, CE marked commercial systems 1017 Measurement of antimicrobial activity and application of clinical interpretive criteria to general bacteria (rapidly growing aerobes) -.01 Anaerobes 1018 Detection of antibody response to infection using appropriate CE marked commercial techniques -.02 Enzyme immunoassay, using CE marked commercial systems 1018 Detection of antibody response to Test/assay #NAME? CSF Fluids from normally sterile sites (other than CSF) Urines Blood Cultures MRSA screens Genital Tract Specimens Faeces Swabs from all sites, including tips Sputum, Bronchial Alveolar Lavage (BAL) & Antral Wash Out. Automated identification (Vitek 2) & conventional identification using biochemical methods. Identification of bacteria using conventional identification methods. Manual Antimicrobial Susceptibility Testing using Disk Diffusion & EUCAST Guidelines Direct examination of faeces specimens for: C. difficile toxins (enzyme EIA) Direct examination of faeces specimens for: Specimen Type Human cells/fluid Equipment/Technique Method (CE/Non- CE/In house developed/based on standard method) Microscope/microscopy Standard method Range of measurement Std. ref & SOP BST/MIC/SOP/005 Manual Standard method BST/MIC/SOP/002 BST/MIC/SOP/014 BST/MIC/SOP/008 BST/MIC/SOP/006 BST/MIC/SOP/016 BST/MIC/SOP/019 BST/MIC/SOP/015 BST/MIC/SOP/013 BST/MIC/SOP/017 Manual Standard method BST/MIC/SOP/002 BST/MIC/SOP/014 BST/MIC/SOP/008 Manual/Automated Standard method BST/MIC/SOP/031 BST/MIC/SOP/018 BST/MIC/SOP/011 BST/MIC/SOP/022 Manual Standard method BST/MIC/SOP/015 Manual Standard method BST/MIC/SOP/015 INAB Registration No. 206MT Page 7 of 8 Edition 1, 12/06/2018
8 infection using appropriate CE marked commercial techniques -.05 Immunochromatographic methods, using CE marked commercial systems 1029 Miscellaneous -.99 Miscellaneous tests Rotavirus & Adenovirus determination (immunochromatograph asseys) Direct measurement of HCG in urine. Rapid immunochromatograph Assay Faecal Occult Blood Manual Standard method BST/MIC/SOP/009 BST/MIC/SOP/015 INAB Registration No. 206MT Page 8 of 8 Edition 1, 12/06/2018
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