Direct result entry into computer

[Dawn]

What is your facility doing?

[John C. Staley]

We are direct computer entry, no paper record. The expectation is that the computer entry be made immediately upon reading.

[CSMILLER]

I am very strict about direct computer entry and immediately as the results are being read.

[catmontgomery]

We recently went from a paper system to a blood bank computer system (SafeTrace Tx/Wyndgate). We enter all our test reactions directly into the computer. Our pre-transfusion workups done on an extended specimen will follow through the surgical visit (within our allowed 14 day extended period).

[bbkdiane]

We actually have a choice of entry methods. All patients have a patient card made up with demographics and work history. The cards function as a work summary or can be used as a downtime worksheet. I have one rule: the test reactions must be recorded dynamically as they are read. The tech can either record them in the computer grid (Misys) or onto the patient card grid then enter them later into the computer. This option works well with new hires or generalists who are a little slower at computer entry. Cards with negative screens and normal blood typing results are purged every 12 months from the file to keep it manageable. Cards with problems are red dotted with an Avery paper dot and kept indefinitely (or until we read the obit). Techs can get themselves into trouble if they attempt to rely on memory. We are burdened with so many interruptions; phones, signouts, surgical needs, AM admit nightmares such as missing Autologous units,unexpected antibodies and my favorite, the last minute request for 4 or 5 doses of platelets STAT for Open Heart Surgery. The techs all know that dynamic entry of reactions is one of my non-negotiable rules. Failure to comply results in a Performance Improvement documentation (reminder) which in itself it non punitive as long as the problem does not occur again. Second occurrence of the same issue within a 3 month period could initiate formal written warning. The interpretation and entry of the patient ABO and Rh result is single most important task that a tech performs. This is a high volume high risk task that must be 100% correct 100% of the time.

[mrhelton]

I am very strict - enter directly into the computer as things are done -- We spent lots of time and money creating control functions in the LIS (Misys) - they have been validated and serve as a monitor for all processes. The only paper entry is performed if the system is down.

[GSD2SABSAL]

I am very strict about this. Each workstation has a computer system built into the station and the technical staff is required to enter the data as they determine the reaction strength. I don't believe there can be any substition on this topic. Its almost like labeling at bedside.

[skopti]

It defeats the purpose of having a computer if you are going to enter ithe results on paper then in the computer. You are duplicating your work and wasting time also increasing your chances of errors.

At our institution we do a direct result entry into the computer.

[MTINGA]

When we switched to our new LIS, many techs stil wanted the "security" of a worksheet. But we found that errors were being made transfering information from worksheet (or card or slip of paper). Anytime you write something down and then transfer info somewhere else, you run the risk of errors. We made a rule that as soon as tubes are taken out of centrifuge and read, results must be put into LIS immediately. No exceptions.

[MicheleKay]

We do direct entry also in Cerner!! Hate Cerner b/c only pathology uses Cerner. The rest of the hospital uses "Last Word." So imagine all the confusion b/c noone is onthe same system!!! We used to review the previous days worksheets and manually make cards for new patients and updated patient histories to use as a back-up. But we recently did away with the card file and now either everyday or each week the sytem is backed up on the hard drive and if we need to access something we can pull it up on a main computer just for this purpose. Otherwise we rely on "PTC" (patient comments) field for special requests like irradiation, known AB's, LRF, CMV=, and most important..BMT's while performing TX's and dispensing.

[Eagle Eye]

We have manual gel(with SA reader) and ProVue. All our results get exported to LIS from SA reader or ProVue(except crossmatches and PAnel). We ask the techs to make print out for panels and crossmatches and they enter result from there to LIS. We have a manual or downtime worksheet for CORD, DAT or any tube method testing as we do not run those on gel. All other records are in the LIS and we have FHR on the back up PC incaseof LIS downtime to look up patient history. We do not have card system at all.

[Diane]

We enter ABO & Rh reactions directly & immediately into the computer so that we can take advantage of the computer system's "Calc Hook" as a check. All other reactions, including a recheck of the ABO/Rh, are written on a worksheet & then final interpretations are copied into the computer.

[CABMT]

We enter results directly into the computer. There's no need to record results twice and transcribing results from paper to electronic leaves too much opportunity for data entry error.

[bpkelly]

We use both methods. We have kept our paper records because we had a 7 day unplanned downtime several years ago and would have never recovered without our paper records. The crash was so quick that there was no time to back up files.

[rcurrie]

We have direct entry only, recorded as the testing is done. We are very strict about this. Of course, we do have "computer downtime" forms, but they are rarely used. We use Wyndgate TX in the transfusion service and Wyndgate Donor in the donor service. I find the donor module results easier to review.

BC

[Sandy Jo]

I came from a facility that utilized direct computer entry when the LIS was implemented. I am now supervisor at a facility that has both manual cards and computer entry. I require direct entry at time of reading to either the card or the computer. But I do see instances where the "other" is sometimes left incomplete. My plan is to get rid of the manual entry cards and keep a card file with patient demographics and problems only, not the actual results. I feel it is much better to have only one DIRECT entry method, less errors.

Sandy R.

[dstoever]

blood bank 101, results are recorded immediatly after reading, like, while they are still

in your hand, either on downtime form or in the computer

[shelleyk482]

We record directly into MediTech. When I first got here (4.5 yrs ago), they were recording on manual logs and then at the end of their shift entering the results into the computer and they had always done that so about half of the staff was very resistant to changing. In order to get buy-in, I formed a team to look at the pro's & con's of changes, identify potential issues & develop plans to resolve the potential issues and to develop an implementation plan. The team was very deliberately put together: 2 techs who were admantly opposed, 2 that were totally convinced and 2 that different have much opinion one way or another.

To make a long story shorter, we drastically increased productivity, decreased transcription errors, decreased record storage fees and increased staff satisfaction. None of the staff would even consider going back now.

[Vaatha]

What is your facility doing?

We use HCLL software from Mediware and enter our results directly into the computer. We do bench tube testing and automated testing-the automated comes directly across to the computer in a "performed" status-all we have to do is verify them. Batch entry, except for automated results, or unit type confirmation, is discouraged-we usually open one patient at a time into a worklist and then minimize, so that only one patient's results are up on the screen at a time. We use paper records for downtime, and since we went live only 2 years ago, and paper records have to be held 3 yrs onsite per our policy, we still have files from before go-live that we are slowly getting checked and stored. If a patient comes in, or it has been >3 yrs, we check the info on the card against HCLL, and then store it away.

[LAS]

CAP requires that results be recorded at the time they are interpreted. If your BB module is your permanent record, then results are entered as the tubes are read.