Kindly share the policy at your facility if you have a Jewett refrigerator or frezer, whereby your circular chart recording malfunction but the digital reading and thermometer readings at the top and bottom shelves are acceptable.

Does any hospital blood bank still record the temperature of that refrigerator or freezer every 4 hours until the circular chart is fixed? or you document the malfunction of the circular chart, stating that the other temperature recordings were accepatble until the circular is fixed.

What is your policy?

Is such a facility going to be cited by either AABB, CAP or STATE.

Kindly share your views.

Thanks

Adenle

Member

Our QA Plan says we will continuously monitor blood storage device temperatures.

In the event of a chart failure, we would use our downtime process, which documents temperatures every 4 hrs.

The Standard 3.6.2 states "There shall be a process to monitor the temperature of refrigerators, freezers, and platelet incubators continuously and to record the temperature at least every 4 hours." (Italics mine) This means that if your continuous recorder is not recording, you must record temperatures manually at least every 4 hours. You will get cited for a non-conformance by AABB if you are not doing this.

CAP TRM.42500 (Phase II) states "For blood/blood component storage units (e.g. refrigerators, freezers and platelet incubators) that lack continuous automated temperature recording, are the temperatures recorded at least every 4 hours?" This is the same requirement as the AABB.

I don't know about your state, but most states follow AABB and CAP pretty closely. I believe JCAHO has a similar requirement, but I don't have immediate access to their standards.

Our policy is to take the temperatures every 4 hours until the recorder is repaired.

We too, would record the temp every four hours until it was fixed.

Same here; we would record temperature every 4 hours until the chart was repaired.

I'm curious, if your alarm is functioning properly and would notify you if the storage device went out of temp and you have someone who would hear the alarm 24/7, why do we need to record the temp every 4 hours? Logically it dosen't make a lot of sense. We're not looking at the chart every 4 hours to see if it's working or if the temperature is being maintained. We depend on the alarm to tell us that. We document the temp seperately every morning and if the alarm dosen't sound then the temp range has been maintained.

Oh, yeah, we do it too, we record the temp every four hours if the chart isn't working. Logic seldom overcomes inertia.

I agree, it is not logical. Are there enough of us here to get AABB and CAP to see it our way?