During our recent CAP inspection, the inspector requested to go to the nursing floor and review the units transfused on the previous day. She wanted to track 4 units that were given and review the transfusion slips. Two of the slips could not be found by nursing personnel, and we were sent on a field trip to surgery and recovery, but the slips could not be located. On the other two transfusion slips, a signature was missing on one form and the transfusion time on the other was more than 4 hours from sign out time. I am now in the process of setting up a review system to track the completion of all forms, as well as review all forms for transfusion time exceeding 4 hours and missed reactions, which have primarily been elevated temperatures and significant changes in blood pressure, up or down. I have found one missed elevated temperature and one missed increased blood pressure in the past month. I am also supposed to check that the transfusion was started within 30 minutes of the blood being signed out, and I have found a few that exceed the 30 minute time limit. This is going to take a lot of my time. I am now caught in the middle between Nursing and Medical Records, in "shoot the messenger mode". We are a small facility that transfuses about 150 units per month, and I pity those of you who will be trying to find and review hundreds or thousands of these records, paper or electronic. Our inspector said this change was prompted by Joint Commission who noticed that a significant number of transfusion records were not being completed during Joint Commission chart reviews. This change was not on the checklist I was given to prepare for the inspection, dated 2006, but was on the checklist the inspectors had, dated 2007. If you have not reviewed the 19 Blood Management Measures recently proposed by Joint Commission, now would be a good time. Much of the data collection will fall on Blood Bank, and of course, as always, no additional personnel and NO OVERTIME!
