Irene59

CAP inspection is looming, and dept director asked if there was a procedure in place for this. Is there a specific blanket SOP that I can write for all the "tube tests" that would cover everything from ABO/Rh to antigen screening, for QC deviation? I don't just mean a blanket "document results on XYZ quality improvement form." I am looking for something to add to each procedure, or a separate procedure entirely that states what exactly to do, i.e., check expiration date of reagent, re-test reagent, etc. etc. For example, in chemistry, the procedure would look like: if QC is outside of acceptable limits, recalibrate, reconstitute, rerun, etc. etc. I have not seen anything like this anywhere for BB

CAP inspection is looming, and dept director asked if there was a procedure in place for this. Is there a specific blanket SOP that I can write for all the "tube tests" that would cover everything from ABO/Rh to antigen screening, for QC deviation? I don't just mean a blanket "document results on XYZ quality improvement form." I am looking for something to add to each procedure, or a separate procedure entirely that states what exactly to do, i.e., check expiration date of reagent, re-test reagent, etc. etc. For example, in chemistry, the procedure would look like: if QC is outside of acceptable limits, recalibrate, reconstitute, rerun, etc. etc. I have not seen anything like this anywhere for BB

There are several different scenarios in place at our institution. 1.) Utilize electronic system, no second draw necessary (preferred method) 2) If not drawn by the electronic system, require a second draw by any phlebotomist, UNLESS 3) Patient has a previous history where there is a type on file. In this case, a second draw is not needed. Of course this is documented in the results, that the patient has a history.

Our lab week has been really good so far! Plant exchange, cookie contest, wig day, crazy earring and socks day, fun facts day (guess the little known facts about each other), sub sandwiches provided by pathologists, lab word scramble and crossword. We also include the off shifts in the food and contests. One evening we are going to PF Chang's, at a time when the third shift can go also. Some of the other posters ideas are great. I'll have to keep them in mind for next year.

Any time the patient has an ABO/Rh ordered, regardless of HX, we do the control. In our computer system, Meditech, there is a line to record the control.

Any thoughts on this would be greatly appreciated. For pre-op patients, how far in advance is the type and screen done at your facility? We only use/draw ours within 72 hours of the surgery. Policy is currently being revised to do a T/S up to a month before the surgery. However, we are not going to use this specimen for the XM. If patient needs blood during/after surgery, a new specimen will be drawn, with a T/S and XM. The purpose of this is to eliminate multiple trips to the facility (one for all other pre-op work, and one for the T/S) which is happening now. If you do have something like this in place, what are the advantages/drawbacks of this? One obvious drawback is if blood is needed urgently, and the whole T/S is being done while the patient is on the table. Thanks for all your input!!!