We just finished with our JCAHO inspection Oct 2018 and nothing was said about how we handled Rhogam. Our pharmacy orders the Rhogam inventory since Rhogam is given in the MAR (has a NDC #) and pharmacy gets the revenue when administered. Blood Bank stores the Rhogam and determines who is a candidate. Blood Bank calls the pharmacy when we need them to order more inventory.
I would like to find out what others are doing for doctor's orders and patient consents before transfusing blood products. Does your policy have the nurse verify the orders and consent prior to picking up the product? Is there a second nurse verification of the order and consent before transfusing the product to the patient?
If the patient has a history of Anti-Le(a) and the current antibody screen is negative we perform an IS/AHG crossmatch and do not antigen type the units. If the Anti-Le(a) is active then we will give antigen negative units.
Currently it is not a problem and they have 4 hours from the time of issue to infuse the unit. However we will be going to SafeTrace and EPIC next fall so any information passed on will be greatly appreciated.
We will do an acid elution when the DAT is positive and the mother has a clinically significant alloantibody or the reason for positive DAT is not known. We do not perform an elution when it is due to ABO incompatibility.
We do not notify our Medical Director. We alert the nurse in charge of the patient that the FMH screen is positive, KB stain performed with results in the chart and that the patient needs more than 1 vial of Rhogam. Phone call is entered as a comment under the positive screen for documentation.
We have been on Meditech Magic and Client Server since 1995. When you perform the unit inquiry you can see the patient for whom the unit was issued out to. Inquiry tracks everything and each patient the unit was crossmatched to.
We require direct observation of each method (tube, gel and TANGO) for tech initial training, 6 months competency, and then annual competency for a new hire. All other techs direct observation yearly for each method.
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