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Hi Blood Bankers,

This question may have been brought up in the past, but I did not do a proper search of the forums to see if it has.

 

My Question:

As Blood Bankers, how do you make sure that the Nursing Orders to Transfuse (or Administer) Blood Products are followed - for example...Physician orders Products to be crossmatched but not transfused...Nurse sees that blood is ready (or receives a phone call from Blood Bank that they are ready), does not check the Administer orders and comes down and is issued the product and hangs it.

 

Or second scenario...Blood is ordered to be Administered (and of course is crossmatched).  Nurse never comes down to pick it up from the Blood Bank.  We do not call nursing a second time - once is our practice to call when the blood is ready (plus they can see it in the EMR on their side).

 

Thank you.

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20 minutes ago, David Saikin said:

with our ordering scenario, the MD can provide the order to transfuse w the orders for components.  I do not f/u on orders, we do not have access to the MD order set.  The only time I call is to the OR.  Everything is electronic.

Thank you David,  

Yes, with our LIS the physician places the orders, and nursing follows the transfuse order (lab of course receives and performs the crossmatch order).  Now due to the incidents that I mentioned above, our Quality Management team is questioning why Blood Bank issued products without a Transfuse order.  The only way I can view the tranfuse order is by going in to the EMR and viewing all of the patient's orders - kind of an invasion of privacy if you ask me.

 

 

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Similar to David, above.  When a unit is ordered, it is ordered for transfusion.  We have exceptions for OR, atypical antibody patients, and things like massive transfusion protocols.

Scott

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We phone once.  When a nurse signs out the blood (electronic) we have a place where they must confirm the consent form and the physician's order to transfuse is on the chart.

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FIRST SCENARIO:

We have Epic as HIS and it has a module called BPAM which allows patient/unit bedside scanning. When we receive order to Prepare product we complete the order and it available for nursing to see that it is ready in the EMR. When nursing is ready to Transfuse they must "release" the Transfuse order in Epic. A copy of the released Transfuse order that includes patient id'ing information and the component and any special requirements. If we don't get the released Transfuse order we don't issue the unit MAINLY because, if they didn't do the release correctly they will not be able to scan the unit into the EMR at the bedside hence delaying the transfusion and possibly wasting the unit.

 

SECOND SCENARIO:

We frequently get Prepare orders but the unit is never transfused. That is not an issue for us since it doesn't affect our inventory in any way. We do mainly computer assisted crossmatches so we don't actually "crossmatch" the unit to the patient until the do the release Transfusion order (see above). The only crossmatches we do at time of Prepare order are those patients who don't qualify for computer assisted crossmatch i.e. have antibodies.

If there was an issue as you described above I would write up a Safety/QA report and as long as you were following SOP then the onus for transfusion errors is on nursing not blood bank especially if you cannot see the orders.

 

 

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Nursing orders to transfuse are just that - NURSING orders.  The blood bank does the testing required for the product orders received and makes sure blood products are available and/or ready.  If the RN/courier appears at the window to pick up a product and we have a valid product order, we will issue the product.

It is very frustrating when the lab gets blamed when the nursing staff cannot follow/clarify a physician order.

 

 

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We have had similar issues with nursing coming to get the product for transfusion but not checking the physician order to transfuse.  We now have it on the check list which they have to approve in the computer prior to transfusion.  This change did make a difference however we still had one nurse check the box and they did not confirm the order.  There was a great deal of discussion about why the blood bank released the unit when there was no order to transfuse, however I explained we often do not have access to physician orders.  I suggested  a solution was for nursing to bring the printed order down each time a unit was released.  This would ensure they checked and had the order and we could then easily verify it.  Needless to say nursing did not go for that solution.

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On 7/11/2019 at 2:17 PM, pbaker said:

Nursing orders to transfuse are just that - NURSING orders.  The blood bank does the testing required for the product orders received and makes sure blood products are available and/or ready.  If the RN/courier appears at the window to pick up a product and we have a valid product order, we will issue the product.

It is very frustrating when the lab gets blamed when the nursing staff cannot follow/clarify a physician order.

 

 

This is how we treat it.  I have no way of verifying that there wasn't a verbal order from the physician to transfuse.  We do have the physician order to transfuse on their checklist as well, and there have been nurses who just checked it and went about their transfusion without an order.  I have to explain several times a year that it is the Dr.'s responsibility to order what he wants, Lab's job is to prepare what the Dr. orders, and the RN's responsibility to carry out the physician's orders.  Not always popular, but we can't babysit everyone.

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2 hours ago, BankerGirl said:

This is how we treat it.  I have no way of verifying that there wasn't a verbal order from the physician to transfuse.  We do have the physician order to transfuse on their checklist as well, and there have been nurses who just checked it and went about their transfusion without an order.  I have to explain several times a year that it is the Dr.'s responsibility to order what he wants, Lab's job is to prepare what the Dr. orders, and the RN's responsibility to carry out the physician's orders.  Not always popular, but we can't babysit everyone.

Before I answered the question I wanted to wait and see what other people had to say.  BankerGirl, thank you for your last sentence.  It is a philosophy I had followed all of my career.  I understand the argument that everyone is responsible for the patient's well being but at some point you have to draw the line and make everyone responsible for their piece of the process.  

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22 hours ago, John C. Staley said:

Before I answered the question I wanted to wait and see what other people had to say.  BankerGirl, thank you for your last sentence.  It is a philosophy I had followed all of my career.  I understand the argument that everyone is responsible for the patient's well being but at some point you have to draw the line and make everyone responsible for their piece of the process.  

Thank you for your comment, John.  My statement is also not popular with my Laboratory Director, but it is true none the less.

 

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Truth is important, but the appropriateness of such a statement should be measured by its usefulness.  

Scott

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We also use Epic BPAM for administration, so if provider orders are not in the system correctly and nursing doesn't release those orders, BPAM won't work. They've been learning that the hard way. Some nurses still like to point the finger at Blood Bank, but their IT folks can see when the problem is user error rather than a lab issue. They educate nursing staff accordingly. There are still problems, but at least nursing management knows where the problems originate and some of the front line nursing staff is getting pretty tuned in to BPAM.

When blood products are in a 'completed' status in Epic at my facility, a little red blood drop shows up at the top of the nurse's screen in Epic, something like the 'new test results available' notification works. They still call sometimes, but that little drop has helped tremendously. We do communicate by phone if the patient has antibodies or there is some other reason for delay. We might also notify surgery or the ED that blood products are available in some situations, but not routinely.

When the provider signs the Transfuse order in Epic, a copy of that order prints in Blood Bank. When the transfusionist releases the Transfuse order, a copy prints on the floor and in Blood Bank, so we know that they are ready to start the transfusion. The nurse who comes to check out a blood product brings the Transfuse order that printed on the floor when the order was 'released', which serves as positive patient ID for us. Works well for us even if it does kill trees. 

 

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23 hours ago, SMILLER said:

Truth is important, but the appropriateness of such a statement should be measured by its usefulness.  

Scott

True, Scott, but I learned a long time ago the difference between talking to my coworkers/director and communicating with those outside the lab.  My director still freaks out when I tell her that, but I try to remember to mention that those weren't the "official" words I used.  I still take offense to the physicians who want to blame lab for their failure to order tests and the nurses failing to follow instructions, though.  I have learned never to respond in the heat of the moment if it isn't absolutely necessary.

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So after an unforunate (and reportable) event where an ECC patient got transfused with RBCs instead of intended FFP, we made changes in Cerner.  There is a crossmatch orderable and a seperate Transfuse orderable - the Transfuse order generates a page on the Blood Bank printer, which must be on hand prior to issue.  Exceptions for emergency, MTP, and OR cooler issue.  Babysitting at its best!

 

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1 hour ago, Byfaith said:

There is a crossmatch orderable and a seperate Transfuse orderable

We have the same set up for basically the same reason - a patient was transfused with no transfusion orders.  However, blood bank only gets notification of the product order.  Also, no specimen collection label will generate if only a transfuse order is placed. 

We had a case where a transfuse order was placed on one patient and a product order was placed for a patient with a VERY similar name on the same floor.  RN came to pick up blood for the patient with the transfuse order and couldn't understand why we did not have it ready.  "Patient was bleeding!!!!!" 

Our transfuse and product orders are going back to being linked together so you can't order one without the other.

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We set our blood product orders to reflex off of the transfuse order.  This accomplishes two things for us:  the physician only has to enter one order, and we don't have staff calling us and asking if they need to order irradiated, cmvn, leuko-reduced, etc.  We perform electronic crossmatch (sorry Malcolm, that's the term) so we do not set units up unless they have a transfuse order unless they have a clinically significant antibody (or history of one) or the patient is in OR and the physician requests units be packed in a cooler for quick access.

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We supposedly had physician order entry for transfusion orders. The order printed n Blood Bank and the nurse brought a copy to obtain the blood. We had instituted a blood management program with stricter reasons for transfusion. The reason was required on the order and we double checked the entry - if they marked HGB less than 7, not bleeding, and the HGB was 7 -9, we usually completed the order, but sent the transfusion for review.   They could only order one unit at a time in a non-bleeding patients with HGBs between units.  HGBs greater than 9 would require approval, if non-bleeding. We also documented whether a nurse or physician actually entered the order and that was reviewed -with doctors having nurses enter transfusion orders being contacted.   There were other reasons for transfusing and we had a paper transfuse order for OR or downtime.  Instituting this process was a lot of work at first, but we cut transfusions by close to 40%. 

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