AABB Standard 5.1.6.2 &CAP TRM.31375

[luhubert]

CAP states "Is there an appropriate inventory control system in use to track the use of all lot numbers of critical materials. According to the checklist, a "critical material" is a good or supply used in the collection, preservation, storage, testing or TRANSFUSION of blood components ant directly affects quality or patient safety (for example, blood collection sets).

What is everyone's opinion on tracking blood administration "Y" sets and if we should, how should we go about it?

[L106]

I doubt that nursing personnel is recording the lot numbers of the blood administration "Y" sets. (Correct me if any of you know differently.) However, hopefully, they should be doing and documenting some type of evaluation of these types of supplies (especially before switching brands, etc.)

[mmblisard]

Lu,

Just FYI- I was inspected recently by CAP and got a deficiency on this question because I was not logging when I threw away or gave away any reagents to the local MLT program. I have always tracked in inventory but never logged a final disposition. I called around to several other facilities and it seems no one else (but the inspecting facility) is logging out either. I just took the hit on it, but now log a final disposition of reagents.

[bbbirder]

CAP states "Is there an appropriate inventory control system in use to track the use of all lot numbers of critical materials. According to the checklist, a "critical material" is a good or supply used in the collection, preservation, storage, testing or TRANSFUSION of blood components ant directly affects quality or patient safety (for example, blood collection sets).

What is everyone's opinion on tracking blood administration "Y" sets and if we should, how should we go about it?

Any idease about the Y-sets? I have this question also. Are blood administration sets critical materials? Yes or No?

My guess is that most places don't track the lot numbers.

Thanks!

[AMcCord]

I (reluctantly) decided to call them critical materials. We capture the lot # of the infusion set on the transfusion record - used to be on paper, now electronic. Compliance is good and I don't get any grumbling from staff. The checklist explanation states that anything that directly affects patient safety qualifies and there have been some recalls due to sterilization failures of infusion sets. That's how I sold it to Nursing administration. They had no problem with it.

Edited November 23, 2009 by AMcCord

[S.Hunt]

Currently our central supply area logs in all lots of transfusion sets in an on line master log. They started doing this after there was a recall and they had no idea where the received sets were destributed.

Basically the form lists the manufacturer - product -lot# -Expiration date (when applicable) - and number of units. When a unit/case/or multiple sets are distributed, the materials staff member performing the transfer, documents it.

You should have a Master List of Critical supplies used in your Blood Bank/Transfusion Service/ or Blood Collection site and a tracking plan for these supplies just like for a blood product -> birth to final disposition.

Good Luck - it took a long time to set up the CRITICAL SUPPLY TRACKING SYSTEM

[L106]

Thanks to everybody for all this information! Your posts have made me realize that I need to follow-up on this topic with our Corporate Compliance Officer.

[korchek]

Please don't advertise in the forum.

Edited November 24, 2009 by Cliff
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