Jennifer88

We still require 2 nurses to identify the patient, witness the scanning of identifiers, and witness and countersign that the nurse/patient checklist is completed. However, I have noticed that some of them can be a little lax in this process and tend to rely more on the electronic checks than they should.

I have a scenario I'd like to share and get some opinions. I was reviewing Nursing transfusion documentation and discovered a patient with no vitals documented at the 2 hour mark. I submitted a request for missing information to the Nurse Manager. She in turn spoke with the nurse performing the transfusion. This is the message I got back: She knew the vitals check was due, but the patient was not in his room. She went outside to look for him because he went out to smoke frequently. She could not find him. When he returned to his room, he told her he had been out in his car smoking and listening to music. He did not tell anyone he was going out and no one checked on him until the 2 hour vitals were due. Keep in mind that this guy is wearing a hospital gown and wheeling an IV pole with a pump and unit of blood attached in the parking lot of a small county hospital, in August, during 95 degree heat, with no medical personnel present. I guess my question is, what policy do you have in place regarding things like this? And does this really happen anywhere else?? My BB techs, Medical Director, and I are the only ones that think this is a problem. I know we can't physically force a patient to stay in bed. My suggestion is to talk him into waiting, but if not the transfusion must be ended. I feel pretty stupid to even post this. I have it on the agenda for the next transfusion committe meeting. I want to be armed with information before I go in. Thanks!

We are trying to implement extending the expiration date/time for pre-op Type and Screens for negative history, non-pregnant, and non-recipient of product patients. We use Meditech. Does anyone have a rule that would automatically change the specimen expiration based on a couple of parameters? Thanks!

Thanks for all the information and ideas. I understand it better now. Now all I have to do is get it through Lab Admin and submitted to CAP!

We just had CAP Inspection. Although there is a policy in place for Lookback, we were cited because we did not specifically state what to do for internal deviations or unexpected events other than the hospital wide error policy. Would anyone be willing to share SOPs and forms for this? I am trying to respond to this, but I am not exactly sure what all needs to be included. Thanks!

Thanks for the suggestions. We are now HFAP accredited, not Joint Commission. We just had our HFAP survey and got very lucky in the charts that were pulled for review. We are a smaller county hospital where a lot of the staff have been here longer than they can remember so any "new" ideas are not readily accepted or followed. We have been live with the electronic transfusion record for 7 weeks. My current audit shows about 40% of charting is complete...mostly missing vitals. This is not an improvement from paper charting, even though I was told repeatedly that the paper was the problem. I present my findings in 3 weeks at the Cross Functional team meeting (we do not have Transfusion Committee, long story!) My best resource for help and information is this web site, so appreciate the help!! I also audit transfusions live periodically. I know that if we have a recurrence of this at CAP inspection we are in deep doo. I'm trying to get Nursing and Administration to appreciate the seriousness of this. I'm just getting a little frustrated at this point!

My first CAP inspection as Blood Bank Department Head last spring was going great until the part where they follow the unit to observe nursing starting the transfusion. At that point it went all bad fast! My question is what are the consequences if that should occur again? We use Meditech and recently implemented the TAR electronic record but I am still seeing a lot of non-compliance with nursing. And, unlike the Lab, they do not write up and counsel the nurses when the problems are listed. My Administrator is anxious to bring them into line and has asked me to find out what could happen if things still aren't at an acceptable level by the next inspection. Any comments or suggestions are welcome! Thanks! Jennifer