Unit Tag Completeness

[vav5325]

Just curious on other Blood Banks protocols on checking for completeness of returned Transfusion Cards. Our protocol has it that the nursing staff complete the transfusion card. top copy of the card goes on the patient chart while the bottom portion is returned to the blood bank. The techs in the blood bank check to see if everything is filled out. If certain portions of the card aren't filled out we then give the card to the manager. Our current transfusion card is printed with a dot matrix printer. We are currently switching over to Horizon Blood Bank software (SafeTraceTx) and most of the unit tag templates are for laser printers. Just wondering if a copy of the completed transfusion card has to come back to the blood bank or is it ok for it to be just on the pts chart. Thanks in advance.

[John C. Staley]

We stopped getting anything back from the nursing units years ago. Instead I implemented a semi-annual chart audit to review documentation. Worked great for me and took a lot of the time and pressure off my staff. Besides we never saw any improvement the old way. With the chart audits I was able to interact directly with nursing and we did see improvement.

:juggle:

[swede]

Nothing is returned to our blood bank. We send one laser copy of the transfusion form with the unit of blood, and it is placed on the patient's chart. This has been done since the early '90's and we have had no problem with inspectors.

We do follow units to the floors several times/week and follow the whole process. Those transfusion sheets are observed for completeness at that time.

[SMW]

You may need to check local/state requirements when making your decision. For example, the state of New Jersey requires these forms to be returned to and reviewed by the Blood Bank.

[Mary**]

:blahblah:The same is true in Indiana. It is a lot of work and does not seem to improve the process.

[tgarrison]

You don't have to receive the card back, however if you are like us we use this as a quality monitor for JCAHO. Our nurses record the vitals, reaction, signatures, etc exclusively on the hang tag.

[mcgouc]

After our JCAHO inspector couldn't find the transfusion information on several charts he pulled, we switched to doing what John does. Only we review about 40 transfusions per month after the charts are scanned in the computer. Since we have all the transfusion information on the tag, we check for the tag to be in the medical records and have 9 items we check on the tag. Some of the items we check are: the two signatures for identification at the bedside are on the form, the transfusion was completed within 4 hours, the vitals are complete and "on time" per policy, etc. We use this as a quality monitor. We found we were getting the back copies in the lab, but they weren't getting the chart copies in the appropriate place on the chart so it didn't make much sense for us to be checking the back copies. Currently, the copies are usually on the chart and the completion stats are much better, but I don't know if we will ever reach 100% on the information being complete. As John says, it does give us interaction with the nursing staff because we take the incomplete forms to the floors. We include all floors that transfused blood in the audit, but everything else (shift, component transfused, etc.) is random. On the last JCAHO, they checked several charts and the info was there.

[tgarrison]

About what % is 40 records? How many units do you transfuse per month?

[mcgouc]

About what % is 40 records? How many units do you transfuse per month?

That is about 10% of the components we transfuse each month. The 40 components usually represents about 15-20 patients which is a little over 10% of the patients we transfuse. We try to make sure each floor is represented according to the number of units they transfuse. However, since we don't give much blood to OB patients, there is almost a 100% audit of their transfusions. A floor that transfuses a lot would have a lower percentage of their transfusions audited.