Reviewing Physician written orders

[Skinrash]

I'm from an approx. 200 bed community hospital where we have 1 Blood Bank tech on days, 1 on second shift, and a floating generalist on the night shift. I'm wondering how many Blood Banks out there actually have to physically see and review the physician's order for transfusion prior to issuing a blood product? Currently we do not, but our VP of clinical services is pondering the idea.

[Malcolm Needs ☆]

I won't vote in this poll, as I work in a Reference Laboratory, but I will suggest a follow-up question.

Of those who are required to actually see what the physician has ordered, how many can actually, hand on heart, say that they can read the physician's hand-writing?????!!!!!!!!!!!

:devilish::devilish::devilish:

[Deny Morlino]

110 bed hospital here and we do not see the physician's orders (normally). On occassion the floors will have difficulty with figuring out what the physician is attempting to order and will after a phone consult with lab fax a copy of the order to our department to see if it makes any more sense to us (most of the time we can help). As a routine we do not see the physician's written order. We are nit-picky enough in lab without going to this extreme of hand-holding and micro-managing the orders for lab. Just my 2 cents worth.

[Likewine99]

We do not see and have never seen the physician's hand written order.We are now on an electronic Med Record so this is probably a moot point.

I could go along with "input from the Blood Bank" but I think it is unreasonable to expect Blood Bank staff to interpret every order written. What do your Quality/Risk people have to say about this?

[Mary**]

I totally agrre with you Deny, but unfortunately, we are stuck with reviewing the physician's order to give. It all started when a doc wrote an order to transfuse platelets. The patient had both blood and platelets assigned in blood bank and we issued the blood and it was transfused without untoward effects. However, we went through a "Sentinal Event" investigation and nursing compared the Blood Bank to the pharmacy which reviews all orders before dispensing drugs. We lost the battle and will be doing it forever. And no, Malcolm, we can't always read them. We sometimes have to ask the nurse what it says!!:bonk:

[krichards]

For your VP pondering this idea: Do you require the techs to look at the physician's written order for every CBC, CMP, etc? Do you require pharmacy to look at the same orders for every drug dispensed?

[lalamb]

We are a small hospital and we do require to have a copy of all blood bank orders, esp for out patients. This is mostly to make sure unusual/infrequent items aren't missed (do titre if AB ID is pos, need irradiated products). Also to have dates of surgeries and to confirm DOB. No good way to document surgery schedule in the LIS (in a place that won't get missed).

When nurses come down to check out a unit of blood, they need to bring down a signed copy of the "patient has been informed of transfusion risks and has consented to recieve blood" document. (we had to start doing this as of our last inspection. If the Dr hasn't signed the document, we send the nurses back to get it. Not so much of a problem now as everyone is used to it and they are prepared)

The nurses stick the patients hopital label on this signed doc , so we have their Med Record #, DOB, acct #, and name, all on 1 document. All of this info is read to the nurses and they read it back to us, before they walk out w/the blood.

We actually feel good about this as some rare tagging snafu's have occured. Better to fine out BEFORE the unit leaves the lab.

Might not pharmacy and blood bank have something in common?

We are issuing something that will be inject INTO the patient. Miss labeled/wrong test hemo,chem specimens have the possiblity of being recognized as wrong, via the delta check. If a Dr gets a test s/he didn't order, oh boy, will you hear about it. Can always rerun a test.

Edited September 14, 2010 by lalamb

[tbostock]

We are nit-picky enough in lab without going to this extreme of hand-holding and micro-managing the orders for lab. Just my 2 cents worth.

I totally agree; I have concerns about faxing a physician's order to me (that I may or may not read correctly), and the nurse neglects to fax me the next page where the physician cancelled the transfusion order. Unless we have the entire chart at our disposal (electronic medical record), I think this is putting BB staff at risk. Physicians are responsible for obtaining consent and writing orders, nurses are responsible for picking up orders. Too much "babysitting" on our part puts us in a place where I don't think we legally belong. OK, there's my rant for the day.:tongue:

[reidhospbb]

We started requiring the nursing staff to fax a copy of the physician's orders to the blood bank any time there is a blood order involved whether it be an order for a crossmatch, to transfuse, or to disregard an order. I always felt that if it was required by the pharmacy staff that to maintain the "standard of care" that we should be doing the same for the "therapeutic" substances we dispense from the blood bank. There have been several errors averted because the blood bank staff actually read the physiican's orders and corrected an error that a clerk or nurse had made. The blood bank is responsible for the recipient's welfare (that's why we crossmatch the blood) and if we neglect to verify orders are we fulfilling that responsibility?

[AMcCord]

Transfusions are documented into an electronic medical record here. One thing that the transfusionist must document is that she/he reviewed the physician's order prior to transfusion. Do some of them just say 'Yes" without really looking? I'd bet on it, but I haven't been made the policeman...yet! Hopefully not ever because I already have way too much paperwork.

[Skinrash]

Thank you for everyone's valid points. These are the very same issues we are currently going through. Our pharmacy sees every written order for what they dispence, so many are wondering why the blood bank doesn't do the same. And as expected, folks here are questioning our processes because of a near miss incident that triggered a root cause analysis. In the end, it was declared that the nursing staff simply misread and did not understand the physicians order. Not only is the process spelled out in the nursing transfusion policy that the TWO participating individuals must verify the existance of a physicians order for transfusion and signed consent, but must also sign a certification statement that they did so on each issue/transfusion form for each blood product issued. Right now I have to side with the argument that those nursing and clerical staff upstairs have to follow established procedures and be held accountable. My believe is that our process if very cleary spelled out, we should expect people to perform their job as expected, and stop shifting the responsibility to others. Our Blood Bank will always gladly assist in the process of clearifying an order, however if it still unclear, our staff (nursing and lab) has to have reasonable critical thinking skills to call the physican for clearification. Again, thank you for everyones debate! Carry on Blood Bankers!

[dpapararo]

We check every physician order against our computer entry. We request that the floor fax down a copy of the physician's order. No fax, no work done. We also require that the person coming to pick up the blood product bring a copy of the physician's order so that we can check again.

[Mrasmus1]

At our facility (240 beds) our nurses are required to check the physician order on the chart when they receive the unit and are performing bedside identification of the unit with the patient.

[David Saikin]

The only time I want to see the original order is when I am questioning its interpretation, eg, too many STAT orders. I have found that most of the time this is not the written orde but the Nurse/ward clerk think it needs to be so . . .

[roberman]

We ask that all orders are faxed. We have many (older) physicians ordering Type & Hold x2, which we see as a Type & Screen, but the unit secretaries and nursing staff often order as Type & Cross 2 units. Also the default in Meditech is for 2 units. If the person ordering is not paying attention and the provider only ordered 1, we end up crossing an extra. Our pathologist has devised a "Blood Product Order" form which the physician is supposed to complete. In addition to the order, the provider must check off the reason for the order, and any special requests (irr, autologous, etc.). Now we have to get them to consistently use it. The nursing staff also must bring this down to the lab when they come to pick up a product.

[mjshepherd]

I won't vote in this poll, as I work in a Reference Laboratory, but I will suggest a follow-up question.

Of those who are required to actually see what the physician has ordered, how many can actually, hand on heart, say that they can read the physician's hand-writing?????!!!!!!!!!!!

:devilish::devilish::devilish:

AMEN!

[mjshepherd]

We require a copy of the physicians order before setting up units on a patient, exceptions of course for the OR and ER

[macarton]

We had an incident in which an RN checked out blood & gave without looking at the doctors orders which was crossmatch for surgery only. The patient for some reason thought he was to be transfused & kept bugging them as to when was he going to get it. We had another issue in which blood was given & platelets ordered. Another red cells given instead of FFP post CV surgery. Also due to the confusion between FFP & platelts with the nursing staff in which they have ordered FFP instead of pheresis which resulted in us wasting the FFP, we now require a copy of the orders at the time the order is placed in the LIS.

[hughes]

no, staff is not required to see the written order, they only see the product order which directs them what to set up.

[L106]

Right now I have to side with the argument that those nursing and clerical staff upstairs have to follow established procedures and be held accountable. My believe is that our process if very cleary spelled out, we should expect people to perform their job as expected, and stop shifting the responsibility to others.QUOTE]

Skinrash for President!!! Now, if we could just get the "powers-that-be" to accept and enforce that philosophy! Excellently expressed, Skinrash!

Donna

Edited October 8, 2010 by L106

[GilTphoto]

We require a copy of the signed consent and a copy of the doctor's order.

It's to make sure we are giving out the right product, and that it's indicated.

We had a couple of cases that caused us to review orders.

1. Doctor ordered: crossmatch 3 units RBC's and transfuse 2. (Nurse transfused 3)

2. Doctor ordered: transfuse 10u of Cryo if Fibrinogen < 150. (Fibinogen was 650 and nurse transfused)

[Eagle Eye]

we do not see physician order but question each and every order and if order doesn't meet our transfusion guidline supervisor comes in picture and try to get more information from resident or clinican and if not justified then medical director gets involved.

We also track all transfusion review cases which requires medical director involvement and present them to transfusion comm.

[KarenJ]

We used to require it for FFP, but that was mainly to be sure they were actually planning to GIVE the FFP, not just "hold" it. Now with the physicians entering their own orders in the computer, thety have to order FFP for transfusion, which generates a "task" for nursing to give the FFP. No transfuse order, no products. So far it seems to be working.