Joint Commission - Documentation of infusion rates

[pinktoptube]

We have in our blood administration policy that transfusion is given at a slow rate for the 1st 15 mins and then can be increased; we do not state this is documented. An inspector asked us for documentation to prove the rates we are using during a transfusion. We do not have a way to document this, does anyone document their infusion rates and changes to during the transfusion? 

The are citing PC.2.01.01 that blood transfusions are administered according to state laws and approved policies. 

[Neil Blumberg]

Another inspector who is a bureaucratic and clinically ignorant rigid thinker.  My sympathies. There is no reason to document early infusion rates, and these vary by patient due to clinical condition. This is just a guideline and not a requirement, as the inspector would know if they had any bedside clinical practice experience.  Just say it's a rough guideline, not a requirement, and clinical judgement will determine the infusion rate for each patient.

[Tessa]

Over the past year, I have had JC inspect over 25 of our transfusion service sites. Over the course of these inspections, I was exposed to 4 different inspectors. Their actual clinical experience ranged vastly. Most of our sites detail in the policy the infusion rate for the first 15-30 minutes and then base on clinical condition. From your description, I could probably guess who your inspector was. 

Edited July 17 by Tessa

[applejw]

Our system uses Epic as HIS and rates are defined within the Transfuse orders.  The documentation is in Epic where you can see the starting rate and any rate changes.  We also have had TJC examine transfusion rates to ensure that nursing is following the ordered rates.