CAP proficiency testing for blood bank

[ElinF]

When reporting CAP proficiency tests for all other areas of the lab we order the test in the LIS and report. For blood bank we do not do this because of the needing to use a unit of blood. Should we be creating fake units so techs can report their proficiency tests into the LIS?

Thanks!

[SMILLER]

In our lab we have some areas, like Micro, that use the LIS in this way to record proficiency results. Mostly we do not bother, as we already have to enter it online to submit results, and adding the step of ordering faux tests and resulting them on the LIS is redundant. Why do you feel a need to use the LIS at all?

Scott

[Eagle Eye]

we create donor unit in our LIS, order tests in LIS and result them,,,same like real patient.

[Likewine99]

We enter the samples in the LIS as "patients" with a standardized naming convention. Order the tests and they pass over to the BB IS. Enter the donor unit in inventory like it was a PRBC.

When survey results come back discharge pts in BBIS and discard the donor unit. Have passed several CAP inspections throughout the lab using this method.

[Mabel Adams]

I never wanted to put them in my live system because it would alter my inventory and statistics called up from the computer. Meditech had a separate function for doing surveys that kept it out of the regular patient database, but you couldn't put units in there either. I have thought of doing it in a test or train system but then everyone would have to remember his password to the test system to do a survey. Maybe that would be a good thing.

[tbostock]

I believe you should do proficiency samples as close to how you test/result patient samples as possible. So we built it in our live system. We name the "patients" a name that is obviously a proficiency sample (put the CAP number and date as part of the "name"). And we made a fake group code (you could call it CAP or PROF) so that the units would not be in our RC group code for red cells, so that our statistics and inventory would not be affected. It works really well, and seems to make the inspectors happy that we perform them like patients.

[BANKTECH]

We also enter the CAP testing into our LIS system as well as the donor unit. For the donor unit, I place a comment on the unit so there is never a question that it is not a real unit. Seems to work well for us.

[David Saikin]

We also entered the CAP samples as pts and the donor unit into our BBIS. As TBSTOCK does, we had our own inventory of CAP (vs rbc/lrbc/etc). We were also able to use the unit for multiple pts since it was only in xm status.

[Sandy L]

This was a recommendation from a CAP inspection stating that we were not treating our CAP survey samples as patient samples. We now do as Likewine99 and tbsotock. We assign an ISBT product number based on our Facility Identification number, year 99 and last 6 digits based on the CAP number and similarly register patients. This does create several extra units per year in our statistics. I think we will add a Final Disposition reason to our BB LIS to indicate that it is a Survey sample.

[Eagle Eye]

we dispose the unit in our LIS after the survey is faxed so it doesn't affect our statistics.

This was a recommendation from a CAP inspection stating that we were not treating our CAP survey samples as patient samples. We now do as Likewine99 and tbsotock. We assign an ISBT product number based on our Facility Identification number, year 99 and last 6 digits based on the CAP number and similarly register patients. This does create several extra units per year in our statistics. I think we will add a Final Disposition reason to our BB LIS to indicate that it is a Survey sample.

[DOGLOVER]

When reporting CAP proficiency tests for all other areas of the lab we order the test in the LIS and report. For blood bank we do not do this because of the needing to use a unit of blood. Should we be creating fake units so techs can report their proficiency tests into the LIS?

Thanks!

The gen lab orders and results CAP or API samples in the LIS (Cerner Classic) but in the BB we use our paper downtime system. I have never had an inspector even mention it. It also is a way of making sure people are proficient with the downtime system. Results are entered on-line to CAP and API.

[SMILLER]

We also have never had an inspector question why we do not bother to enter proficiency cases into our BB system.

Scott

[OxyApos]

A couple of things to consider. We have "test patient" protocols in our system ( Sunquest) so the result would never be confused with a real patient. The relatively few Type and Screen & XM results over a year are not an issue with skewing our statistics. I have the results entered into our LIS so that I am proficiency testing our staff on results entry per our protocol also. BUT, in theory, we have multiple hospitals , so one of our other sites could try to look up one of these "test" patients and see our results. This is something I do for in house competency. Inspectors have been happy to see my master list of surveys, staff members, and who performed what to be compliant.

[sgrassley]

We have Cerner Classic. I created a Product specifically for the Cap Unit: CAP-U. I turned off all compatibility checks for the product - since sometimes the Unit is not ABO Compatible. And I can easily exclude this unit in the monthly reporting.

[JoyDenver]

In our lab we have some areas, like Micro, that use the LIS in this way to record proficiency results. Mostly we do not bother, as we already have to enter it online to submit results, and adding the step of ordering faux tests and resulting them on the LIS is redundant. Why do you feel a need to use the LIS at all?

Scott

As a COLA Surveyor, I always recommend the Blood Banks I inspect to create Proficiency testing patient files and rbc files into their LIS so that it can be used as a very comprehensive competency assessment. Not only are you assessing the performance of the test, but computer entry skills.

[SMILLER]

We do use the test system on our Mediware BB system to set up various training scenarios. Everything on that system is a mock up. Normally its used to validate software upgrades.

We have used it in the past for such elaborate (and critical) practices as the release of uncrossed matched products for massive transfusion prorocols. But here, there is no actual testing being done (which is what our JCAHO and FDA inspectors focus more on).

Scott