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Requirements for Issuing Blood Products?


ritaberry

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Do you require a copy of the written order and/or consent form to be presented by the transporter to pick up blood? We currently require only the patient's full name and medical record number to be presented in written form. Most transporters use an ID label from the patient's chart.

We've recently had several orders placed in the computer system for blood products for patients who had not consented to receive them. We also have had orders for the incorrect blood product, such as liters of plasma for a therapeutic exchange that was written on the chart by the physician to be performed with Albumin from the Pharmacy. Irradiation orders have been overlooked.

Another hospital in our city requires a copy of the physician's written orders to be presented to pick up blood. I've heard of others requiring a copy of the consent form. I'd like to address this at our next Transfusion Committee meeting and it would be good to have an idea of what other facilities are doing. Asking Nursing Service to change a procedure can be challenging, especially if it requires additional steps. I'd appreciate any comments.

Rita Berry MT (ASCP) SBB

Transfusion Service Supervisor

Baptist St. Anthony's Health System

1600 Wallace Blvd.

Amarillo, TX 79106

(806)212-4337

rita.berry@bsahs.org

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We use a "Request for Issue" slip that the nurse completes for the transporter to present to the blood bank. The slip has check-off for the product wanted and seperate check-off area with the criteria for the transfusion. It must have name and MR# or DOB, but most often a patient label is on the slip. I will try to scan and attach a copy in the next 2-3 days.

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We have a "blood request" form for pick up. We do not require a copy of the MD's orders or the consent. For special products (irradiated, cmv=, etc): if we have the pt on file with those requests we honor them (except for emergent need), we would not know if the MD ordered something "special" unless we are informed (verbally or on the order).

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We do not require a copy of the MD's orders or the consent. Someone from the nursing unit (secretary, nurse, or physician) enters the "Issue" request in the computer.

Our stand is that it is the physician's (or nurse's) responsibility to ensure that the patient has signed the "Consent for Transfusion" paperwork. Similarly, it is the nurse's responsibility to check the physician's written order and ensure that the correct type of blood product is ordered and transfused.

However, I understand your comments about the challenge of getting Nursing Service to change and/or accept responsibilities. Do you have an active Risk Management/Quality Assurance type of Committee that oversees the entire hospital? Seems like they should have jurisdiction over patient care matters such as missing Informed Consent documentation and transfusion of the wrong type of blood product.

Donna

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We started asking for a special Physician's blood order form a while back (it would have had the product orders and had room for irradiation and other stuff too) - the Dr's did not take to it at all. We had less than 25% compliance with most of that being the RNs transcribing phone orders. Now we mostly get photocopies of the real Dr's order and a photocopy of the consent form. We have caught missing Irradiation orders a couple of times, caught that there was no witness or pt's signature on the consent forms, etc. If you are going to do this - I would recommend just asking for photocopies of the Dr's orders themselves - don't try to add a new form to the system. I now prefer to see the real Dr's order - we notice things sometimes that mean something to us that did not mean anything to the RN and did not wind up in the computer orders. Still lots of phone calls though!

Introduction of this procedure was really rough - took 2-3 months to work out all the kinks and the RNs did not like it at all. We ask for the same set of paperwork each time they come down and that really bothers the ICU/CCU units on a busy pt. (Oh - the O.R. does not participate in this procedure - they still just bring a small pickup card with band number and pt ID sticker.) The system bothers me too in that while they used to go to the bedside to get the BB ID band number each time - either a sticker or write it down - they now place a sticker (Typenex band) on the consent form and just photocopy it each time. So.... there are positives and negatives to each system. We have solved some problems and created others.....maybe electronic medical records and bedside barcode reading of units will solve all of our problems!?!?

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Our system prints out labels to attach to the unit, and has a separate attached slip that is a "Unit Ready" slip. That slip gets sent to the floor. The nurse brings that down with her/him (edited to be politically correct with gender!) It has all the info on it: unit #, type, patient name, DOB, MR#, BB band #. If they don't bring that down with them, we ask for a demographic label with the blood bank band # written on it.

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At my current hospital we do not ask to see the orders or consent. We will shortly go to an electronic medical record, so the physicians will be entering their own orders and answering consent questions, that we will have access to. For now on the request form, the nurse has to sign that she verified the orders and consent before picking up the blood.

At my previous hospital we used to see the consent. The nurses had to bring it with the request for blood each time, because we had no way to file them, or keep track of who was discharged, readmitted, etc.

Be careful when accepting nursing's responsibility (verifying that physician orders are correct) and physician's responsibility (becoming the consent "police" to keep the docs in line). Although it is good for patient care, it puts the Blood Bank at risk. I'll give you an example: nurse faxes you down the page from the chart "transfuse 1 unit packed RBCs". You set it up, nurse comes to pick it up, transfuses the patient. We find out later that on the next page of orders, the physician wrote "cancel transfusion order". Guess who got blamed...the Blood Bank was found at fault, even though they did not see the subsequent order in the chart to cancel. So...unless you have access to the entire medical record, be careful about accepting just one page out of the chart.

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I understand your comments, Terri. You are correct that Blood Bank does not have access to the entire medical record, which is why at our institution the physician (or whoever has total access to the pt's medical record, which is usually a nurse or unit secretary) enters the order for the crossmatch into the computer (just like they would order any other Lab test.) And if they want to cancel something, they must cancel the order in the computer (or, if the test has already been received in the Lab, they must call the Lab and tell us to cancel it.)

I hope you have better luck with the physicians entering their own orders than we have seen. We started physician order entry a couple years ago, and suddenly respect for the unit secretaries rapidly rose when many physicians decided it was "just too difficult" (and found ways to get around the system to avoid entering the orders themselves.) I would love to see data on what percentage of orders are entered by the docs.....I'd bet it's less than 50%, possibly even less? (Good, patient training sessions with the physicians is so important.)

Donna

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With our current paper system, the nurse is required to document on the transfusion record that the consent and order to transfuse have been verified. We have had instances where one or the other were not present and the patient was transfused.

We are in the middle of implementing an EMR system where the release/dispense slip and the nursing flowchart are generated from the physician's order to transfuse, so we can at least be sure that there is an order. Consents will still be on paper, however, so we are requiring that the nurse verify consent and document that in their flowsheet.

I would be adamant about the blood bank not taking responsibility for items in the patient chart when the blood bank staff does not have access to it.

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We require only patient identifiers and the BB band number to issue products. Soon the rest of the hospital is going to start facing scrutiny similar to what labs have seen for years so they might as well get used to taking on their responsibilities. JC & CMS are starting to monitor things like form completion and consents more thoroughly, I think. In order to get "meaningful use" money for health IT we will have to have physicians enter at least 80% (maybe it was even 90%) of their orders themselves. Right now, I think we are at about 60%. We have had EMR for quite a few years and changed HIS software in 2009. They mess up A LOT entering orders so we keep trying to make it easier for them.

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We use BloodTrack - so transporter (trained porter, nurse aide, or nurse) must have their barcoded ID scanned, and we have the Compatibility Report barcoded, which they must scan at the issue fridge and BloodTrack Kiosk. Without these (and them being valid or if there is no blood for that patient) the Issue Fridge Electronic Lock will not open. Also we get an audible and visual alert on the system (opened always in BBank Lab and in Quality Office) that someone is using the kiosk in error. Their identity will be known if they have scanned their ID barcode. Closed lots of non-conformances for us when we installed it three years ago.

Cheers

Eoin

Edited by Eoin
clarity
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  • 2 weeks later...

We currently use a pick up slip and require the nurses to check the transfusion order and consent and document on the transfusion record. We are preparing to require the physicians to use a transfusion order set that has check boxes for the reason for transfusion. We are hoping to capture a picture of appropriate use in this fashion. The form is designed so that it can be computerised when physician order entry is implemented (at some unstated VERY future time). Is anyone else using a system like this to capture appropriateness of use data?

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We require the patient's information-name and MR at the time of issue. There is a "read back" process.

Every quarter we do a Transfusion Audit---follow a transfusion to the floor and document the process of two signatures, consent form, staying with the patient during the transfusion etc.

I would be hesitant to police anymore--once you identify a problem --you take ownership of it.

Is your Risk Assessment dept. involved with the order mistakes?

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Rita,

We use a Request for Blood Product form which has patient info (matching that of the patient bracelet); the patient ABO/Rh type, the type and number of products requested at this pick-up, a place for the transport personel to sign that they have recieved the product, and a place for the BB to record the unit number of the unit issued. And we keep this for our records.

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We use BloodTrack - so transporter (trained porter, nurse aide, or nurse) must have their barcoded ID scanned, and we have the Compatibility Report barcoded, which they must scan at the issue fridge and BloodTrack Kiosk. Without these (and them being valid or if there is no blood for that patient) the Issue Fridge Electronic Lock will not open. Also we get an audible and visual alert on the system (opened always in BBank Lab and in Quality Office) that someone is using the kiosk in error. Their identity will be known if they have scanned their ID barcode. Closed lots of non-conformances for us when we installed it three years ago.

Cheers

Eoin

Eoin,

This sounds like a fantastic system; can you tell more of the pros and cons of it's use?

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We currently use a pick up slip and require the nurses to check the transfusion order and consent and document on the transfusion record. We are preparing to require the physicians to use a transfusion order set that has check boxes for the reason for transfusion. We are hoping to capture a picture of appropriate use in this fashion. The form is designed so that it can be computerised when physician order entry is implemented (at some unstated VERY future time). Is anyone else using a system like this to capture appropriateness of use data?

We have a very nice Physician's Blood Order form that was designed by our pathologist and introduced through the Medical Executive Comm of the hospital. We have less than 10% compliance with using the form. The Drs here just flat refuse to use a new form or a different form from the one that they already "free text" all other orders on. Same thing happened to a specially designed form for chemotherapy orders. Capturing "appropriateness of use" is now being done by actually getting a copy of the original Dr's orders and we are ranging between 30-40 % compliance with putting any transfusion indications on the charts. I do hope you have better luck.

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Apparently our institution has had great success with requiring a form for insulin ordering from the Pharmacy, so my administrator expects the same level of success in mandating a form for ordering routine transfusion. We shall see if he is right. First we have to get the Med Exec Comm to "bless" it.

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Is anyone using a blood request entry through the HIS to the BBIS? I don't mean a xm order; I mean when they are ready to transfuse a unit they enter a "test" in the computer which prints a label in the Blood Bank that provides all the identifiers so that the blood can then be issued to either a volunteer or maybe via pneumatic tube. Of course, I guess they would have to choose the right patient, but we require the BB band number too so that should help. At least the info should be legible this way.

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Is anyone using a blood request entry through the HIS to the BBIS? I don't mean a xm order; I mean when they are ready to transfuse a unit they enter a "test" in the computer which prints a label in the Blood Bank that provides all the identifiers so that the blood can then be issued to either a volunteer or maybe via pneumatic tube. Of course, I guess they would have to choose the right patient, but we require the BB band number too so that should help. At least the info should be legible this way.

Mabel - That is pretty much exactly the set-up we have at our institution. The only difference is that we do not require that the ordering person tells is the BB band number (which, by the way, I do like your idea to do this.) (We call it an "Issue" order when they are requesting that we issue the blood to be transfused.)

Donna

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No, we don't. I would love to, but "the powers that be" purchased and installed our hospital's pneumatic tube system without asking for any input from those departments that would utilize it the most! (Surprise!!...Here's your tube system!!) Therefore, our tubes are not large enough to transport most donor units safely, and the pneumatic system is too violent/rough. (When a tube lands, it hits the receiving station like a bullet and sounds like a small explosion.)

Perhaps some day our system will "bite the dust" and we will be able to replace it with a "real" pneumatic tube system.

Donna

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We have one "Lab Assistant" working in the Blood Bank. She delivers most of the blood to the nursing units and Surgery, etc. However, we also have trained all the Pharmacy Technicians to deliver blood, so when we need help (because we are busy, or it is the weekend or 2nd shift, etc) we page the Pharmacy Tech. He/she comes to BB, checks the donor unit info with the BB Tech, and delivers the blood to the nursing unit (or Surgery, or wherever.) I am pleasantly surprised at how helpful and careful the Pharmacy Techs are. We started this about 5 years ago and it has worked better than I had imagined.

(If a nurse ever came down to pick up a unit of blood I would have a heart attack!!!)

Donna

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