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During our recent CAP inspection, the inspector requested to go to the nursing floor and review the units transfused on the previous day. She wanted to track 4 units that were given and review the transfusion slips. Two of the slips could not be found by nursing personnel, and we were sent on a field trip to surgery and recovery, but the slips could not be located. On the other two transfusion slips, a signature was missing on one form and the transfusion time on the other was more than 4 hours from sign out time.

I am now in the process of setting up a review system to track the completion of all forms, as well as review all forms for transfusion time exceeding 4 hours and missed reactions, which have primarily been elevated temperatures and significant changes in blood pressure, up or down. I have found one missed elevated temperature and one missed increased blood pressure in the past month. I am also supposed to check that the transfusion was started within 30 minutes of the blood being signed out, and I have found a few that exceed the 30 minute time limit.

This is going to take a lot of my time. I am now caught in the middle between Nursing and Medical Records, in "shoot the messenger mode". We are a small facility that transfuses about 150 units per month, and I pity those of you who will be trying to find and review hundreds or thousands of these records, paper or electronic. Our inspector said this change was prompted by Joint Commission who noticed that a significant number of transfusion records were not being completed during Joint Commission chart reviews. This change was not on the checklist I was given to prepare for the inspection, dated 2006, but was on the checklist the inspectors had, dated 2007.

If you have not reviewed the 19 Blood Management Measures recently proposed by Joint Commission, now would be a good time. Much of the data collection will fall on Blood Bank, and of course, as always, no additional personnel and NO OVERTIME!

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set up a quarterly audit. Go with the transfusionist and check off all requirements.--including informed consent, tag stays with bag, etc.

this will make everyone more aware.

we also do a 10% review of all tags returned to our department. incidents are filed when needed.

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We transfuse approx 150 units per month. Our not-returned rate along with our 'returned but incomplete' is less than 2%. This is alot of work, but consistency makes it easier. Our techs review slips in the AM as part of 'morning routine' and inventory resolution. They make calls to the floors, send notices, and if needed go to the chart. With what I think are good numbers, the job now is not that time consuming.

I suggest you meet with nurse educators/managers for a re-education of the importance and regulatory requirement of unit tag return, times, signature, etc.

I have in the past, sent 'notices' along with the unit at time of issue. You can make them up in word. Just remind the RN to return the completed unit tag following transfusion etc,etc. I would change the notices from time to time for variety. It really does work!

We also have a 'stamp' for the Blood bank copy with the reminder .

I hope the suggestions help.

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I had this "chronic" non-completion of transfusion forms also. Denial was the 1st defense until I used completion of transfusion forms as a QA monitor for a few years. Yes, it was a lot of work but compliance became >95%. I have subsequently dropped the transfusion tag and sign out components with a compatibility label. All documentation is now part and parcel of the Nursing transfusion protocol. To date I have not seen any compliance issues with completion of this form.

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New Jersey State requires 100% review of transfusion record and blood bank is responsible for compliance. It is a very big task for hospital like mine (~450 bed hospital, >1000 component every month). We have to check for temp rise and state wants us to audit ASAP and take action(eg. if there is a temp rise missed by nursing, we are suppose to audit, identify and workup the specimen) so it is very important for us to perform audit in timely manner.

I track and trend incomplete forms, >4 hrs transfusion, missing record, >2F temp rise. You need a support from nursing administration otherwise you will never reach to your goal.

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I monitored 100% of transfusions when we were on paper (avg 165 RBCs per month). I started out sending incomplete forms to the guilty party with a note asking for completion of the record - and don't forget the chart copy! I also had a spread sheet to make note of the type of error (omitted vitals, incorrect unit #, etc) plus the nursing unit involved. If a flow sheet was missing, we called the unit to speak to the nurse or leave a message - x 2 if necessary. Then we sent a written notice to the nurse. If a second written notice was needed, it went to the unit manager. The spread sheet information when to staff development. Compliance improved dramatically when folks started getting "nastygrams' from us. Nurse management backed us, which was very important.

From there we looked for a pattern - was one individual consistently making the same errors, was one nursing unit responsible for a particular problem(s), was it a time period of unusually heavy workload vs staff, etc? At that point, copies of the actual incomplete records went to the unit manager for action. And we got action! I don't know what was said or done, but we got improvement. After about 18 months, we were looking good. It was a lot of work at first, but it paid off. Make a friend in the nursing management hierarchy who can help you and then keep barking up that tree!

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We used to monitor 100% of the returned transfusion forms but after several years and after we were satisfied that we were getting compliance consistently up to our targets, we have dropped it to 100% review for only one month per quarter. The nursing managers all get this Quality Monitor report for their areas each quarter, so they know we are still watching. I'm sure if we dropped it altogether, the noncompliance would sky-rocket back up. I'm looking forward to moving to the bedside electronic transfusion record, so that we can just run reports for our data and not hassle with inspecting each form and trying to figure out illegible handwriting.

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AMcCord,

You are right...you need to make a friend in teh nursing management. It took us approx. 12 to 16 month to get where we are now. We are not @ 100% compliance but we are happy...we transfuse a lot so it will be really hard to get 100% COMPLIANCE.

Edited by aakupaku
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  • 1 month later...

We require nursing to send a copy of the completed form to the transfusion service. We get between 85 and 92% returned. We then review them and any with missing or incomplete documentation are returned to the nursing unit for completion. Unfortunately this is where we have problems if the patient's have been transfused and medical records gets involved. It is an ongoing project. I do a written audit one month per quarter and it is reported to nursing management and transfusion committe. We are finally seeing some improvement after years of stressing the importance of completing the records appropriately. Unfortuanately it does fall to the blood bank and it is very time consuming.

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