We have order sets available to providers, but will go into action with a phone call for MTP and emergency release. The order does need to be placed for that to happen. The patient comes first. CAP specifically says that blood products the patient needs should not be delayed so as to endanger that patient by sticking to paperwork rules. The orders do need to be placed as soon as it is feasible, but sometimes some of those orders are placed by lab. Our procedures spell that out.
TRM.40770 Life-Threatening Situations Phase II
Adequate policies and procedures have been established for the investigation and
handling of life-threatening situations (such as the use of uncrossmatched blood or
abbreviation of testing) that include the written authorization of a qualified physician.
NOTE: Written policies and procedures must be available to expedite testing for transfusion in
a life-threatening situation. If an institution's procedure allows abbreviated testing in massive
transfusion situations, records should indicate that the procedure was followed. Records must
include the authorization by a qualified physician. (If approved by the institution and recorded
in the laboratory's procedures, the physician responsible for the transfusion service laboratory
may accept this responsibility.) If an incompatibility is discovered on completion of an incomplete
crossmatch, the responsible physician must be notified in a timely manner and this notification
recorded.
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Transfusion Medicine Checklist 08.21.2017
Red blood cells released before testing has been completed must be conspicuously labeled
as uncrossmatched on the tag or label. Records of completion of compatibility testing for units
released uncrossmatched must be maintained.
Evidence of Compliance:
✓ Records of emergency release authorization by a qualified physician
REFERENCES
1) Food and Drug Administration. Current good manufacturing practice for blood and blood components. Laboratory controls.
Compatibility testing. Washington, DC: US Government Printing Office, 1999(Apr 1):[21CFR606.151]
2) ibid. Records and reports. Records. Washington, DC: US Government Printing Office, 1999(Apr 1):[21CFR606.160]