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Monitoring incomplete transfusion tags


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Currently our Blood Bank receives the back copy of the transfusion tag from the floor/OR and was cited by CAP for tags that were incomplete with either vital signs and/or 2 signatures. I'm trying to discontinue the practice of getting these tags back. Nursing does perform audits on the completed transfusion tags and the Blood Bank performs monthly observations. The med. director does not want to discontinue as she wants to ensure that the tags are being completed. Any ideas??

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Not sure if just not accepting the tags back is going to do the trick. I do not think that CAP or the FDA cares which department is responsible for reviewing tags, just that it is done and that some area has a policy covering it. Likewise, I don't think your administration is going to care who dropped the ball if the hospital is cited by a regulatory agency.

Having said that, I suppose the department that has a policy stating that a review is done is responsible. I does seem to be a waste of time having both nursing and BB do the same check. Sounds like you need to have your directors consult on this. But in the end, if your pathologist wants a BB review, youre gonna have to do it.

Here were looking at the EHR requirements coming up. How do you review a tag when you dont actually have one any more?

Scott

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What CAP standard was cited to show that it is Blood Bank's responsibility (rather than nursing) to monitor the filling out of tags or EMR seeing as the completion of these is a nursing function?

The citation was TRM.41450 Blood Administration. I'd like to know what other facilities are doing so that the Blood Bank does not take the hit for this since it is a nursing issue.

Thank you!

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The blood bank is responsible for blood components from the time they enter the institution until they receive final disposition. (except the FDA says once you release them you don't have to file a BPD). It is not good practice to let nursing audit themselves. Classically, they get lazy/sloppy. In many of my AABB/CAP inspections, I have discovered a Nursing completion rate of less than 50% compliance. I continually beat my nursing staff over this issue. It is an ongoing battle.

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Now why haven't I thought of that...just beat the nurses. JUST kidding...

My state DOH cites us for this, and as David stated, anything nurses do with blood is in our jurisdiction. We review all of them that come to us, and they are frequently missing vitals or signatures. We highlight them and send them back for completion, which is not 100% successful. Every time I get cited by the DOH or Joint Commission, I use it to plead my case for a bedside blood admin computerized system that prompts for all necessary documentation so you can't just leave blanks. Until the $$$ becomes available, we will forever be stuck with missing documentation on paper.

We also at one point had the nurse manager review them before sending to us...they still came incomplete, because it looked "OK to them". So now they won't look at them anymore. So if you don't have leadership buy-in and accountability, you're stuck with something that you can't fix.

If anyone is still on paper like us, and has come up with a solution, please post to help all of us.

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Clerks and techs spend hours every week mailing unfinished tags back and forth here just like you do.

Thing is, starting next year, EHR is going to mandated, with more stringent requirements increasing through 2014. Tags will then be obselete. You may not be using a computerized system for recording vitals now, but you will be soon. The question is, how do we document review? Is it even necessary to the extent we do it now? A computerized record should be able to alert the transfusionist when they enter, say, an increase in temp beyond 2 C -- all at the time of the transfusion. (In theory anyway)

Much better than the days-later review system we use now, where a possible reaction can be missed and not noted on a review for days in some cases.

Scott

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Terri,

We are still totally paper..though they have promised me the Blood bank computer module in May. Having just taken over, and finding no policy as to what they had been doing (I know that nothing was done from May until September). We get a copy back with the two signatures and the times the transfustion was started and finished. No vitals. I have been checking these for completeness and that they were properly billed (we do that manually here in the BB). I have a meeting set up with the head of nursing education to set up some inservices on how to properly fill them out then set up a "corrective action" for when they are not.

One thing I have learned in the 2 1/2 months I have been here is that nothing gets fixed fast...But I keep after them until it does.

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Clerks and techs spend hours every week mailing unfinished tags back and forth here just like you do.

Thing is, starting next year, EHR is going to mandated, with more stringent requirements increasing through 2014. Tags will then be obselete. You may not be using a computerized system for recording vitals now, but you will be soon. The question is, how do we document review? Is it even necessary to the extent we do it now? A computerized record should be able to alert the transfusionist when they enter, say, an increase in temp beyond 2 C -- all at the time of the transfusion. (In theory anyway)

Much better than the days-later review system we use now, where a possible reaction can be missed and not noted on a review for days in some cases.

Scott

Hi Scott. We already have our EMR (Epic), but they do not have an FDA approved transfusion administration module. So we are still on paper. Do you know of a specific EMR mandate that would mention transfusion administration? Because that would help me tremendously in convincing the powers that be to purchase the necessary software that would accomplish this. Thanks.

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:eek::cries:We have the same issues. We tried to go to a EHR and it was a DISASTER and returned to the tags, at least for now. The EHR did not have any "checks" to alert them and the were not near a computer when they were in the patient's room.It is the State Board of Health here who holds us accountable and they are NEVER satisified and alway find "something" WE missed!

I will never get over having to monitor their work, when I have never given a unit of blood in my life!

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Thank you, David. How doyou perform the review/monitor these tags? Do you receive a back copy when the transfusion is completed, and if so, do you save the copy of all transfusion tags?

The transfusion documentation is on-line (paperless system) . . . very obtuse to find all the data. I try to review daily and forward results to lab and nursing admin.

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Clerks and techs spend hours every week mailing unfinished tags back and forth here just like you do.

Thing is, starting next year, EHR is going to mandated, with more stringent requirements increasing through 2014. Tags will then be obselete. You may not be using a computerized system for recording vitals now, but you will be soon. The question is, how do we document review? Is it even necessary to the extent we do it now? A computerized record should be able to alert the transfusionist when they enter, say, an increase in temp beyond 2 C -- all at the time of the transfusion. (In theory anyway)

Much better than the days-later review system we use now, where a possible reaction can be missed and not noted on a review for days in some cases.

Scott

We have started electronic documentation by nursing, it has not been easy. Here are the problems so far:

1. We don't have ability to utilize barcode entry yet, so nursing can enter anything they like in the donor number (unit number) field, which makes it really hard to track which unit was actually transfused when entry errors are made. Also can enter anything they like in the BB armband # field.

2. Took awhile to get nursing to understand they needed to include the aliquot letter when entering the unit number.

3. We had to designate result fields as mandatory so that it required nursing to enter results or they would skip fields.

4. Vitals are documented in a different place in electronic record and nursing did not want to have duplicate documentation steps for vitals. It is a challenge to link pre and post vitals for transfusions in electronic medical record.

5. ER and OR will not utilize electronic documentation, therefore we are still requiring paper documentation for all transfusions at this point, until we can get ER and OR on board.

These are the problems that come to mind immediately. I'm sure there were more. It has been a real challenge and we are currently looking at other ways (with Cerner) to make this process more user friendly.

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When it came time to stop getting transfusion tags back and use just a single copy that was posted in the chart, the first thing we did was review our transfusion tag to make sure it did not include any documentation not required by those agencies that inspect/assess the transfusion service such as blood pressures, temp, ect. Then I reviewed every transfusion that occurred during a 3 month period for completed forms in the patient's chart. (300+ bed level II trauma center). When it was discovered that we did not have a big problem I began doing the chart audits for 30 days each quarter and submitting a report to the nurse QA group. Also, when I discovered a problem I took it immediately to the the nurse manager of that unit. This system worked very well for me and the inspecting agencies seemed to accept it.

:clone:

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We review every transfusion tag for completeness as it arrives back in the blood bank. Any tag that is not filled out properly has a varience filed electronically. This varience must be answered by the nursing manager as to the action taken to resolve the problem. Most of the time the manager has to confront the guilty party... It has started to reduce the % of tags that are not properly filled out. A report of missing, 2 nurse signatures and the name of the nursing unit, is also sent to our compliance officer monthly for Joint Commission's National Patient Safety Goals compliance. People usually do the right thing when they know they are being watched! It a very effective tool until we go completely electronic...

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Now why haven't I thought of that...just beat the nurses. JUST kidding...

My state DOH cites us for this, and as David stated, anything nurses do with blood is in our jurisdiction. We review all of them that come to us, and they are frequently missing vitals or signatures. We highlight them and send them back for completion, which is not 100% successful. Every time I get cited by the DOH or Joint Commission, I use it to plead my case for a bedside blood admin computerized system that prompts for all necessary documentation so you can't just leave blanks. Until the $$$ becomes available, we will forever be stuck with missing documentation on paper.

We also at one point had the nurse manager review them before sending to us...they still came incomplete, because it looked "OK to them". So now they won't look at them anymore. So if you don't have leadership buy-in and accountability, you're stuck with something that you can't fix.

If anyone is still on paper like us, and has come up with a solution, please post to help all of us.

Our system works pretty well, although not 100%. We require the nurse at the end of the transfusion to return the form to BB in person. We then check for completeness, reactions, and sign off if all is well, and give chart copy back to the nurse. If there are any errors, we do not sign off but BB supervisor (me) goes directly to the nursing director or charge nurse for clarification or correction of a problem. For example, we had 4 missing forms for the month of November and a team of nurses then is responsible to go hunting. The slips usually end up on the patient's chart but 2-3 times a year it's entirely missing and we incident report those. Eventually we aim to go to bedside (paperless) transfusions with our upcoming software transition-can't wait (we are currently still on paper in BB and have about 5K transfusions per year).

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