aj2018

This is my first instrument validation/install. We currently have an Ortho ProVue as our blood bank analyzer, we also use manual gel and tube. We are getting a new Immucor Echo. Can anyone help with the validation of a new instrument. Can anyone send me a validation plan they followed before when implementing a new analyzer. How many different samples used, what types, how many different antibodies..etc. Also, I assume I need to correlate both instruments along with manual tube and manual gel?? we will be doing type and screens, panels, Cord bloods..etc. thank you

Can anyone tell me what kinda policy they have for blood/platelet/plasma transfusions for patients who had a bone marrow transplant.. What kind of blood platelets and plasma do you give them before engraftment/ during engraftment while they are converting and after engraftment? thank you

We are having a problem with our transfusion record form being filled out completely by the nurses, so I'm thinking maybe it needs to be simplified. I was wondering if anyone can send me a copy of their transfusion record form so I can get some ideas on what it looks like and the minimum info needed on it. currently, the nurses do document all the vitals, but we are having problems with them forgetting to have another nurse sign it even though they do the bedside checks together, forgetting to put the component number, or ABO/Rh, sometimes forgetting to put patient identification on the form (I'm thinking this is probably since its down at the bottom). I would appreciate any forms you can send so I can take a look. thank you

Does anyone have a procedure in place that they can email as far as techs to use when they thaw and relabel plasma to thawed plasma... Also, our blood supplier wont provide the labels..is there a specific vendor that you purchase a roll of labels from? thanks

We waste a lot of FFP when its only good for 24 hours after we thaw it. I'm looking into putting a procedure in place to change the FFP before the 24 hours are up into thawed FFP with 5 day out date. I was hoping someone has a procedure in place they can send my way for me to copy and use as a guide. Also, if they can tell me what I need as far as labels and changing ISBT product codes if needed... thanks

Im thinking about adding cord blood testing to our Provue. We already do ABO/RH QC but to add Cord blood testing, I need to work on adding a QC for the DAT. I know I can use any patient sample as my DAT NEG QC sample, but what about DAT POS QC?? I was wondering if anyone can share what they do for DAT positive QC...someone told me I can use an Rh positive patient sample and add anti-D to it, but not sure about how much Anti-D to add etc... thank you

I need to put into place a policy for providing HLA matched platelets, platelet crossmatching, and providing granulocytes for transfusion. I was wondering if anyone can help that has a policy already in place that they can send me a copy of so I can make a similar one. thank you in advance

I need to put into place a policy for providing HLA matched platelets, platelet crossmatching, and providing granulocytes for transfusion. I was wondering if anyone can help that has a policy already in place that they can send me a copy of so I can make a similar one. Thanks

How often do you send a patient out for an antibody ID to your reference lab? do you do it every time they come in and have a positive screen? do you do it on inpatients every three days and get a positive screen? what about patients with colds or HLAs previously identified. if you have two or three cells positive but can still rule out all significant alloantibodies, do u still send it out? is there a rule or a standard that talks about the frequency a workup has to be done..

CAP has a custom checklist for blood banks specific to that blood bank and only includes standards that apply to that specific blood bank. Its nice since you don't have to go through the whole master transfusion service checklist to find out what applies to your blood bank and what doesn't... What about AABB? is there a way to get a custom checklist from them or we have to go through all the standards in all ten categories? we are a small blood bank..we don't collect we don't irradiate and we don't pool or make components of any kind..we do limited antibody identification, type and screens, cord/rhogam testing, and very limited antigen typing. thanks for the help

Can anyone help me with pipette caliberation? if anyone has any forms that I can use as templates, procedure to use for the caliberation like gravimeteric or a colorimetric procedure..etc. it will be greatly appreciated. I understand according to CAP and AABB pipette caliberation has to be done semi annually..right? Do I have to caliberate all the MLA pipettes as well as the GEL MTS PIPETTE? thank you

Yes i was talking to one of the older techs at the hospital and it was put forth just in case kinda scenario. But im thinking its time to change that. There is no reason to do more work, waste tech time and also reagents. I just have to find a way to get everyone on the same page as far as checking for blood types and previous history before crossmatching and issuing units.

Apparently at this facility where i just started....they repeat the ABO on the patient EVERYTIME they crossmatch a unit on the same Type and screen tube..so basicly if i do a type and screen at 8am, then a blood order comes in that evening and another tech pulls the tube from the fridge to crossmatch a unit, that evening tech has to repeat the ABO!!! that seems like overkill, waste of time and reagents... i was always under the impression that as long as we have a history of an ABO on the patient in the system plus a valid (not more than 3 days old) type and screen done..we can go ahead and crossmatch units...RIGHT?

I know we need to have two ABO/RH testings before giving the patient any blood. The scenario is as follows... patient came in, doctor ordered a type and screen. no orders for any blood or any component. Do we need to do another ABO/RH??? i dont think so since no blood was given...right ? If this same patient needed blood in the future, we can do another ABO when that time comes...right? thank you..

they were using temp stickers called Safe-T-Vue here but stopped using them a while ago. So im wondering if we can go without using them as long as the coolers are caliberated and we have only a 4 hour time limit the cooler can be out or it has to get re-iced for an additional 4 hours.

Hi , im revising our procedure for sending blood to the OR in coolers. Can anyone send me templates of their procedure, any forms, or tables they use for documentation..etc. something simple in our coolers, we only allow 4 units and can stay out ofr only 4 hours, if they wanna keep them longer we have to go and re-ice the cooler and its good for another 4 hours. I made up a rough draft of a table/form to check out coolers with cooler number, tech initials, time and date of check out and patient information and ofcourse time and date of return. my main question is that are we compliant if we have cooler temp caliberation only or we need to do more. Do we need to have any temp monitor on the units while they are in the cooler at the OR for example those safe-T-Vue stickers that change color or as long as the cooler is back within the time required its ok. thank everyone As far as the fridge in the OR..we have a chart monitor on it only, is that enough or we need to document the temp daily on a temp form just like we do for the blood bank refridgerator in the lab ( chart plus upper and lower thermometer)

We have a transfusion committee meeting quarterly. We discuss blood usage review, doctor's stats as far as xmatch and transfusion, crossmatch/transfusion ratio, units wasted, any transfusion reactions and any emergency release that happened. I was wondering what other things do you discuss at your transfusion committee meetings and do you present any other statistics like Type and screens..etc.. do you discuss only red cell transfusion numbers or alos rhogam FFP platelets etc. any insight will help thank you

I am in need of templates specific to the CLIA Competency Assessment requirements (6). I would GREATLY appreciate any insight into how to handle, but especially any templates in use or being developed so I have a tool to refer to as I begin the process. Thanks in advance.

Thank you. I'm taking it all piece by piece. I'm about to start on the paper work that needs to be sent to AABB for the upcoming inspection that we think might happen in January. next on the list are all the PMs for the equipment and all the checks. One thing I'm confused a little about is the correlation study that needs to be done for CAP..how it should be done since we do testing in tube, manual gel and the ProVue. I know we keep patient antibody IDs indefinitely, but all the daily and weekly reports that get generated overnight from the LIS, I either need to find a place to store it or maybe come up with a table or form to document review day by day or week by week and discard them. Also, im not sure if blood issue paperwork needs to be kept. they apparently put a copy in the patient's chart and we keep a copy!!! Also blood supplier paperwork, im thinking after reconciling the billing every month that can be discarded like blood return slips..etc..

Tricore thank you for referencing the regulations... under the CAP one it says "Paper/electronic signature review must be at the level of each procedure, or as multiple signatures on a listing of named procedures. A single signature on a Title Page or Index of all procedures is not sufficient documentation that each procedure has been carefully reviewed. Signature or initials on each page of a procedure is not required." what does it mean when it says " signature review must be the level of the each procedure or as multiple signatures on a listing of named procedures!!! thank you

Thanks everyone for the great responses. Its all been of great help. I honestly told them that they are spoiled having the ProVue, manual gel and tube with the amount of testing we do. I think we can be ok if we got rid of the analyzer or the manual gel and just kept two instead of all three. I started getting all the CAP proficiency testing in order for this year and next year. I also found old CAP surveys that were done in past years and looked up some through CAP online. Im going to get the checklist for both CAP and AABB and start going through them. They are def missing documentation for some equipment checks esp the quarterly, and semiannually ones. I'm gonna make some new tables and forms to keep track of this stuff from now on. I also started a new form to be used to document observing nurses transfusing units and if they are done correctly. I found the quality plan for the blood bank and the procedure manual. The last review that was done on the procedures was last year sept 2013. Does the procedure manual and quality manual need to be reviewed every year? I know the techs have to document reading the procedures every year right?

I recently took over a small transfusion service. The department hasnt had a supervisor in over 8 months so the paperwork is piled up, nothing is organized, and not sure if we have some things documented or even tracked. Its my first time taking over a transfusion service department so its hard to figure out where to start. We are a small transfusion service, we keep one platelet on hand, we have only about 6 Onegs and the maximum of 20 OPOS units. We use ProVue, manual gel, and tube and we do limited antibody identification. As far as equipment we have one blood bank refridgerator for reagents and units, plasma thawer, platelet incubator and a small FFP freezer along with one cell washer and one centrifuge. I need to get this department in shape...equipment, proficiency testing, testing, temperature documentation, all the reviews that need to be done and what paperwork i need to keep in case the inspectors ask for. We have reports that print daily like patient testing reports that we review. Do we need to keep those for inspections? I understand we have to have forms/tables that outline daily, weekly, monthly, quarterly, annual maintenance on the equipment. Also, forms that show CAP proficiencies are being done by all techs and are all satisfactory. Procedures for all the testing need to be reviewed annually. Im a little bit confused about what I need to have as far as the LIS system as far as checks, documentation..etc.? Any help regarding AABB/ CAP inspections and regulations, any forms that you can pass on that might help will be greatly appreciated. Thank you