[A Blood Bank Rabbit in King Chemistrys Court]

I don't think this is true. Three items in our recent CAP Accreditation Checklist (dated 6/17/2010) address this topic:

TRM.31150 "There is documentation of at least annual review of all policies and procedures by the current laboratory director or designee."

TRM.31155 "The director (or a designee who meets CAP director qualifications) reviews and approves all new policies and procedures, as well as substantial changes to existing documents before implementation."

(CAP defines the "director" as the individual listed on the facility's CLIA registration.)

Donna

Problematic - Since the CLIA director responsibilities do not allow this set of duties to be delegated, the CLIA director must be available 24 x 7 x 365. The CLIA prosgram only appllies to patient testing. If CAP requires all polices, etc. to be annually signed by the CLIA director, then it would be an accreditation requirement.

[Lab assistants helping in Blood Bank]

Just and FYI for those in CA. - For unlicensed staff - see Ca. Business and Professions code 1269 (d) (3) - For MLT's - see CBPC 1260.3 (.

http://www.leginfo.ca.gov/cgi-bin/displaycode?section=bpc&group=01001-02000&file=1260-1275

[A Blood Bank Rabbit in King Chemistrys Court]

This "signing" only applies to patient test procedures, not other policies, procedues or processes, and is currently a hotly debated topic...

[PRP for Tendonitis]

I hate to be lame, but you could "Google" it. There are a number of vendors who supply kits and equipment for this process. There have been three facilities actually inquiring about licensing for this...

[NAT test]

Check AABB Stds also, p. 30, 27th ed. HBsAg, anti-HBc, Anti HCV, Anti-HIV 1/2, and anti-HTLV I/II still required.

[Armbands on Patients]

I have read the threads and have seen many of those situations. Perhaps it is time to go for the money. If your accrediting (or regulatory) agency knew about these non-compliance issues, serious deficiencies and/or out-of-cycle visits might get the attention of those "above".

[Transfusion Reaction Benchmarks]

Here is a link you can use...

http://www.cdc.gov/nhsn/bio.html