Verifying Physician Orders

[Dar]

Approimately 3 yrs ago, risk mgt asked the Transfusion Service to review physician transfusion orders prior to issuing the blood. Now, Transfusion Orders may or may not be placed into SCM directly by physicians. We in the Bank, are using SoftBank, so we do not see the transfusion orders. We have been reviewing a copy of the order if it was written & presented to us, but if they do not give us an order, we have not been questioning them. Now, risk mgt is back & wants us to monitor every order. I have refused to make the staff look into the other computer system for the transfuse order because our issue person is very busy. I am more concerned about matching labels, tickets, etc. Is anyone else monitoring the transfuse order? If so, how? I thought of building a "dummy" transfusion test where the transfusion order could come into SoftBank, but the logistics of keeping in all straight in big users is almost impossible. Has anyone else dealt with this?

[donellda]

We deal with a similar situation. Our EMR is going through a lot of changes to hopefully avoid confusion. Right now the doctor has to place an order for Blood Bank to prepare the product and one for administering the product. We cannot see the order to administer and sometimes that is the only order that is entered. Our Clinical Transformation committee is creating a new order to transfuse which transmits a request to Blood Bank so that we know that there is an actual order to transfuse. I think it will help us. We use Sunquest in the lab and Cerner for the HIS.

[tbostock]

I am not a fan of having Blood Bank techs review physician orders (I believe this is best left to physicians and nursing). But many of us have been put in this position after there are errors. Some Blood Banks have nurses bring a copy of the physician's orders, but I know of a few cases where they didn't bring the next page of orders, which showed that the physician cancelled the transfusion order. So, this is a slippery slope, be careful at looking at partial orders when you don't have access to the whole chart. We are now completely on physician entry in the EMR, and the order prints to us in the Blood Bank, so it has gotten a little better, because we can review the order ourselves if there is any question.

[David Saikin]

We receive a "paper" component request in addition to computer generated orders. This documents the MD orders/informed consent

[jayinsat]

We began doing this about 3 years ago. What a mess! Nurses hated it! We hated it! We did, however, catch MANY errors. These errors included wrong product type requested in the computer, wrong qty, not ordering special processing (irradiated, ETC) as well as orders for hold only with no transfusions. Some nurses were under the impression that if the physician ordered it, they wanted it transfused.

When nursing orders the product in the computer, they fax us a copy of the written physician order. We verify they ordered it correctly. When they come to pick up the product, they bring a copy of the order that clearly states to transfuse set up product. It must clearly indicate "give", "transfuse", "infuse", or something of that nature.

Lot's of work, lots of trees killed.

[mollyredone]

We don't see any inpatient orders. The nursing staff just orders through the computer. Many times the doctor has ordered two units xm'd and when he puts in the order to transfuse, the floor orders another unit instead of coming down to get one of the ones that is xm'd!! Now we know to call before we add on any units and say, "did you know this patient already has units xm'd??"

[dgibaud]

We are undergoing the same process as donellda, using Cerner for our EMR and Sunquest/Misys as our bb system. We have tons of problems when the order seen in the lab doesn't match the transfusion order only seen by nursing.

[L106]

Our Clinical Transformation committee is creating a new order to transfuse which transmits a request to Blood Bank so that we know that there is an actual order to transfuse. I think it will help us. We use Sunquest in the lab and Cerner for the HIS.

That's exactly what we did when we built our test codes. When the floor orders the "Transfusion" to be issued, the order crosses into our Blood Bank computer (Mediware HCLL system) and we compare all the patient info on that Transfusion order against the patient info on the Crossmatch paperwork.

[KKidd]

I am not a fan of having Blood Bank techs review physician orders (I believe this is best left to physicians and nursing). But many of us have been put in this position after there are errors. Some Blood Banks have nurses bring a copy of the physician's orders, but I know of a few cases where they didn't bring the next page of orders, which showed that the physician cancelled the transfusion order. So, this is a slippery slope, be careful at looking at partial orders when you don't have access to the whole chart. We are now completely on physician entry in the EMR, and the order prints to us in the Blood Bank, so it has gotten a little better, because we can review the order ourselves if there is any question.

What computer system are you using? We have physician EMR entry in the Ed and there is some confusion. They will put in an order to "transfuse2 units of RBC" but an order for T&S, and XM is not generated. That must be done seperately. In order to simplify things, we don't know if the order is for transfusion, have available or pre-op. I fear that when EMR goes live for in-patients it will be a mess.

[dgibaud]

We are having a terrible time with physician order entry, and it sounds like what everyone here is going through. The EMR sends a "Transfuse Blood Products" order to nursing, but the XM order isn't always generated. Another twist is that the Transfuse Blood Products order may indicate "irradiated components" while the XM order just calls for regular red cells. This is Cerner EMR w/Sunquest LIS.

We've been live with physician order entry for 3 months now and it doesn't seem to be getting better. The physician educators don't seem to understand the 2-step order process.

[tbostock]

We have EPIC as our EMR and Lab system, but we have SoftBank for Blood Bank. The prepare order comes into SoftBank and orders the red cell order, but then we look at the transfuse order from Epic to see what the physician actually wants to transfuse and that's what we crossmatch.

[AMcCord]

The nurses document that they have checked the physician order in the electronic transfusion flow sheet. We don't double check them. I hope it stays that way, but we have a big trend rolling right now to move as much 'stuff' as possible off of nursing and onto anybody else.

Putting an EMR system into place was supposed to simplify things. Some things it has, but a whole new BIG can of worms has opened up to think about in place of the things we simplified. Heavy Sigh!

[Kathy]

We just went live with physician ordering and the EMR. We are having similar problems. I am wondering if it would be appropriate to have nursing orders to transfuse print to us. Does the doctor HAVE to order the blood product from us, or would that transfusion order be justification for us to place the order in the LIS ourselves? We have lots of cases where we have a whole unit of blood set up per physician order and then they want aliquots throughout the stay. We end up with orders for 5 units of blood when only one unit (five parts) is transfused.

[Mabel Adams]

Same song, 52nd verse. Some of these problems have existed since the days of quintuplicate paper blood bank slips (ordering more when blood was already xmd). I really hate policing nursing. I think they should fix their problems with orders themselves. That said, computer systems need to improve greatly for this. First, they need to display on some sort of dashboard how much of what blood product is already ready. I think maybe Epic does something like this.

We have had nurses transfuse based on xm orders and come for blood when the patient has never been drawn because there was only a transfuse order. We have been live on this version of CPOE since 2009 and it is still quite a mess. If we built it so we got a copy of the transfuse order via computer, then we can't legally create the crossmatch order because in our system the MD will never sign off on it if it is generated in Lab and we are not licensed to take verbal orders. We would have to call the MD to tell them to order it and they probably wouldn't like that or they would never figure out what we are talking about. We have one PA that we have explained transfuse vs. xm every way possible and she just can't comprehend. Good luck. If anyone has a good solution, please share!

[tbostock]

That said, computer systems need to improve greatly for this. First, they need to display on some sort of dashboard how much of what blood product is already ready. I think maybe Epic does something like this.

I have Epic, but don't have such a report/dashboard. It is very difficult to find this info, so we still get constant phone calls, duplicate blood product orders, etc. I'm trying to get Epic to create something that shows units transfused and ready to be issued, but no luck yet. If anyone has anything in Epic that works like this please let me know. Thanks.

[MAGNUM]

after a near miss several years ago, it was decided that for "every" transfusion, the nurse must bring the physicians "written" order for the ordered product AND the transfuse order so that we are able to determine if we are issueing the correct product as the physician has ordered. We have caught several orders in which the physician has ordered one product, but the nursing department has ordered something different, i.e. irradiation vs nonirradiation, cmv negative vs regular units, etc. although it creates a delay in transfusion at times in the long run we come out ahead. plus our techs are required to date and initial the order each time.

[Kathy]

We are considering having our computer system fire off a corresponding blood product order every time a physician orders a transfusion. Does anyone see a problem with this (other than maybe getting a few too many blood product orders)?

[Mabel Adams]

Will you be able to tell a "real" blood product order that you need to set up from one of these or do you plan to just set it up if you get the order and at least have blood ready for the patient, even if it is more units than they really need. If I was going to take responsibility I would almost rather get a transfuse order which made me call the nurse or doc and say there isn't blood ready order some. Over time they might be trained.

[Kathy]

Docs would still be able to order the crossmatch directly from us without ordering the transfusion. One of our required fields for ordering deals with when/why (hold, transfuse, surgery, etc.) they want the product, so orders that are not for transfusion would definitely have that indication printed out on them. Hopefully if we are able to make the system fire off an order for the product when they order the transfusion from nursing, the order for us would indicate that it was for transfusion.

Edited May 4, 2012 by Kathy

[Mabel Adams]

And if there was already blood ready you could cancel it without affecting the nursing order, right?

[Brenda K Hutson]

Wow, another case of responsibility being put onto the wrong people! Should not the Nurse be confirming an order to transfuse, just as she/he would an order to infuse a medication; prior to giving it?? I have never Policed it anywhere; but that being said, it has been being done at my current Institution for some time, prior to me coming (so is still in place). When a Physician enters a Transfusion Order (vs. Testing Order), it prints out to the Blood Bank computer. The Techs. then place it on the Issue counter and it is used to enter the correct Physician (the one who ordered the transfusion; which may or may not be the one who ordered the initial testing), when they come for blood products.

And that has been the main issue I have come across other places; the need to enter the correct Physician requesting the transfusion. What they are asking you to do, in my mind, is not appropriate; they are asking you to do their job. Just my opinion....

Brenda Hutson, CLS(ASCP)SBB

[Bill]

The Blood Bank staff always seem to be put in the role of "policeman." Any documentation that needs to be checked is placed on the Blood Bank staff, whether it be checking MD orders, MD reason for transfusion, RN documentation of transfusion, etc. This is the role of Risk Management and should stay in that dept. Concurrent documentation checks is the best way to keep everyone out of trouble. I have seen this as a collaboration with the coding team and risk management. The increased revenue more than offsets the cost of additional people.