Nursing Transfusion Orders

[Brenda K Hutson]

I have an important question that I need responses to ASAP (due to a battle with our Nursing Dept.).  My predecessor instituted having Transfusion Orders from the Hospital computer system, print out in the Blood Bank.  She did it because 1 time a Nurse transfused when there was no Order on the chart to transfuse.....so decided we would become the "check" for them.

I have never done this anywhere else I have worked (5 places); and certainly don't think it is the responsibility of the Blood Bank to police whether or not Nursing follows their protocol (because when/where does it end....should I take each unit to the floor to make sure they do all of their checks and hang the blood appropriately and document everything?).  I had made it clear to Nursing here when I came a couple of years ago, that when time allowed, I was going to discontinue that printing out.  Then a couple of weeks ago, another Nurse transfused without an order to transfuse (actually, she said the doctor verbally told her to transfuse; and the order was "later" entered in the computer).  So now Nursing wants us to continue to receive this Form so we don't hand out any blood unless we have an Order to transfuse.

Would love to hear what the rest of you do (hoping to back my position....because unfortunately, in the state I moved to, many of the Hospitals "do" look at the Transfusion Order for exactly that reason).

Thanks so much!

Brenda Hutson, CLS(ASCP)SBB

[Auntie-D]

We get an electronic 'forwarning' request - an exact copy of their printed request form - more to allow us to organise our workflow than check up on them. lt has to be signed by the person taking the sample AND the requesting MO. Without both signatures we will not issue the blood in a routine situation. ln an emergency we will take a telephone request and get on with the crossmatch. 

 

ln the UK the tracability sticker gets stuck in the fluids chart and the doctor has to have prescribed each unit before there is anywhere for the sticker to be put.

 

But basically it isn't our job to check whether the blood has been prescribed, only to issue it. 

[tbostock]

There was a case years ago here where the state came in to review a surgical case that went bad. Had nothing to do with the Blood Bank, but when they scrutinized this case they told us that now it would be our job to make sure the nurses did theirs. From then on, we get a printout of their order for blood in the Blood Bank and we match it to what goes out.

As you say above, I agree that it's not our place to make sure the order is there. But ever since then even Joint Commission inspectors have asked me "how do your techs in the Blood Bank confirm the order to transfuse?".

Since we made this change we have had 3 or 4 instances where the nurse sent us a request for a second unit of blood for a single unit order that was already complete. Very sad that their carelessness has to become our problem.

Some Blood Banks that do not want to get the actual printed order will put a statement on the request form that is signed by the nurse with items checked off:

Order verified

Consent verified

Pre-transfusion vital signs performed

At least then you are covering your Blood Bank staff if an extra unit is issued; you had a signed document from a licensed RN to back you up.

I feel your pain on this one Brenda.

[Sophie1210]

This is how they order in our system:

 

Under Transfuse they select which product they want. The Nursing to Administer is automatically selected along with 0.9% NaCl. They then have to check the Set up [Product] and put in if it's stat/routine, how many units, the reason why. Then the order is electronically signed and submitted. When this happens Nursing gets their order to transfuse and Blood Bank gets a requisition printed to set up whatever product they ordered.

 

The problem we encounter is that the doctor's forget they have check Set Up so Nursing gets an order, but Blood Bank never does. Then Nursing calls asking if the blood is ready and we reply "we never got an order." So we've had some delays in patient care because of that. 

[SMILLER]

Here (Michigan, US), we receive an order for a test or product from the hospital system.  Once the product is tagged and available, we call the unit to let them know. 

 

Typically a transporter brings a written order slip when they come to pick up the product.  It includes, among other things, the reason for transfusion, the type of product and the unique BB armband number (that matches the number on the unit tag, specimen used for T&S and armband on patient.)  FDA, JCAHO has never had a problem with these being inadequate for "confirming an order".

 

Indeed, BB here has had to take over functions which you would expect to be monitored by other areas.  Our OR dept. could not handle proper tracking of bone and other transplant tissue, so we have to stock, issue and track it using our BB system.

 

Scott

Edited December 19, 2013 by SMILLER

[OxyApos]

We have been using Epic for almost 2 years and Sunquest in the Lab since 2001.   There is the "prepare..." in Epic that translates into a lab order for us to execute.  Then there is the "transfuse..." order in Epic that is strictly a nursing order.  They cannot hang a component in Epic without a TRANSFUSE order which comes from the physician.  We occasionally have them neglect to order the Prepare and call wondering where their component is hours later.  Epic isn't great but an EMR has helped alot.

 

[Teristella]

Our issue screen in Meditech has a field that says "Physician Order/Consent Verified" and this links to the nursing module. The nurses are required to enter pre-transfusion vitals into a checklist, as well as answer a series of questions, including whether they have an order to transfuse, patient has been educated and consented, IV is patent, etc. If they have finished all of this, the field automatically fills with "Yes" for us, so we have 'proof' that they say they have a transfusion order.

 

This is pretty new for us, we have been educating nurses that they will be turned away in a couple of months if this is not completed (except for OR, trauma, and emergent patients in ED, of course). At least this way nursing indicates to us they have done everything they need to do before picking up a unit. 

 

We were very in favor of having a pickup slip where nursing had to sign that they had done all of these things, plus note the patient's current relevent lab values, but administration did not want any additional paperwork. We were planning to use these for transfusion appropriateness monitoring too. Can't win 'em all I guess.

[bbbirder]

At our facility, it is nursing's responsibility to confirm the order.  In fact 2 nurses are required to confirm the order (due an error in the distant past when blood was given without an order).  Monitoring is done by Quality Care Management (a nurse is the auditor).

I would not want BB to be responsible for this.

 

Linda

[David Saikin]

We have a Blood Component Request form which is completed by the MD (usually the nurse) - we receive a copy of this every time a component is released from the BB.  It has the transfusion orders on it also.  Our primary use of this form is for utilization review.

[carolyn swickard]

We were receiving a photocopy of the physician's orders from the chart, along with a photocopy of the consent form for every pickup.  (Product orders print out on the Blood Bank printers when ordered.)  It worked well for everyone but ER, who had a different computer system for order entry that they "could not" get copies of, so they asked to be exempted from the orders requirement.  Now that we are getting to an Electronic Medical Record (EMR) setup for the rest of the hospital, we were told that the RNs could no longer give us a copy of the Dr's orders at pickup from the system without getting a whole chart printout (yikes!).  (Others have said they could do a single screen print, but most don't know that.  Supposedly, the ER is capable of that too, but they never picked up on it either.) 

 

So...in order to get the whole thing to work around the clock, we had the RNs go back to just bringing a small pickup form that identifies the pt, the BB ID band number and which product they want at the time.  They also still bring the copy of the consent form.  Annoyingly, many are still bringing the pickup slip without any product checked on it.  Since the employee picking up is frequently not the individual hanging the unit, we have to call and ask what they want the person to pick up.  If we wanted to see the orders, we would have to go into the computer (HCA Meditech 5.6.6) and find them.  I resisted that on the basis that we still would not know what they wanted to pickup at any one time, but many times I can't get that from a simple checkoff form either! 

 

The EMR has made getting the patient's orders more difficult for us and the RNs.  They had to build the transfusion orders on the product orders (so we do see some of them) so the RNs had some idea of when and how the Drs wanted the products given, but because the Dr's also wanted a "HOLD" option, they then had to build a separate TRANSFUSE order if they changed from Hold to Give (those we don't see). 

 

Our recent Joint inspector seemed happy and did not mention "how do WE know the RN has an order to give", so we are not checking that (yet!).  Maybe it is a personal thing with some inspectors.  I think that should be a Nursing responsibility and I think our RNs are double checking the order as they double check the unit(s) at the bedside before they hang them.

[Brenda K Hutson]

Just for clarification....when you say a copy of their printed request form....are you referring to the Order to Type and Crossmatch; or the actual Order to Transfuse the Product?

Thanks,

Brenda

 

We get an electronic 'forwarning' request - an exact copy of their printed request form - more to allow us to organise our workflow than check up on them. lt has to be signed by the person taking the sample AND the requesting MO. Without both signatures we will not issue the blood in a routine situation. ln an emergency we will take a telephone request and get on with the crossmatch. 

 

ln the UK the tracability sticker gets stuck in the fluids chart and the doctor has to have prescribed each unit before there is anywhere for the sticker to be put.

 

But basically it isn't our job to check whether the blood has been prescribed, only to issue it. 

[Brenda K Hutson]

So what I have come up with to assist "them" in doing "their" job is:

1.  I am revising the Blood Product Pick-Up Slip such that there will be a line that states:  "I have verified that a Transfusion Order Exists from Provider ________; then there will be a line for the signature of the person completing that ______________.  We will not Issue the blood unless that Form is completely filled out.

 

2.  On the Transfusion Chart Document that is sent with the blood (which I know varies from Institution to Institution as far as how much information they require them to complete......and now more of it can be documented in the computer).....there was already a statement that said "I HAVE IDENTIFIED INTENDED REIPIENT AND COMPARED THIS WITH BLOOD LABEL AND WITH THE UNIT IDENTIFICATION;"so I am adding to that; AND HAVE CONFIRMED THAT THERE IS AN ORDER TO TRANSFUSE."  There are then 2 spaces for the 2 Nurses to sign and date.

 

Also, 3 things regarding your statement that Inspectors wanted to know how you were making sure Nursing was doing their job: 

 

1.  We do follow units to the floors a few times a year and audit their process

 

2.  By adding to our pick-up slip (which is what we have done other places," a line for the Physician "requesting the Transfusion;"' (or something along those lines), that has been our confirmation; and that is then the Name we enter in the computer when we Issue the Product.

 

3.  I can tell you that in 2 places where our Transfusion Chart Copy Forms were actuallyduplicate, carbon forms, we would get the 2nd copy back for the purpose of auditing completion by Nursing.  At one place, we were cited by the FDA because there were too many incomplete Forms.  I went to Nursing administration and we continued to Audit and return incomplete Forms....which improved the process some, but still not to the extent the FDA wanted....so we were cited the next Inspection again (only this time, the CEO made the Nursing Administrator come to the closing meeting).  Because after all, what else can we do?  At some point, Nursing should be made by "their" Management to follow "their" protocols; and they should audit those protocols.  It just seems to me that the Blood Bank is having to be the gate-keeper for more and more of the Nursing processes.

 

But I have no doubt you feel my pain.....as we all do; so thanks so much for your response!  

Brenda

 

"There was a case years ago here where the state came in to review a surgical case that went bad. Had nothing to do with the Blood Bank, but when they scrutinized this case they told us that now it would be our job to make sure the nurses did theirs. From then on, we get a printout of their order for blood in the Blood Bank and we match it to what goes out.

As you say above, I agree that it's not our place to make sure the order is there. But ever since then even Joint Commission inspectors have asked me "how do your techs in the Blood Bank confirm the order to transfuse?".

Since we made this change we have had 3 or 4 instances where the nurse sent us a request for a second unit of blood for a single unit order that was already complete. Very sad that their carelessness has to become our problem.

Some Blood Banks that do not want to get the actual printed order will put a statement on the request form that is signed by the nurse with items checked off:

Order verified

Consent verified

Pre-transfusion vital signs performed

At least then you are covering your Blood Bank staff if an extra unit is issued; you had a signed document from a licensed RN to back you up.

I feel your pain on this one Brenda.

[Brenda K Hutson]

So what I have come up with to assist "them" in doing "their" job is:

1.  I am revising the Blood Product Pick-Up Slip such that there will be a line that states:  "I have verified that a Transfusion Order Exists from Provider ________; then there will be a line for the signature of the person completing that ______________.  We will not Issue the blood unless that Form is completely filled out.

 

2.  On the Transfusion Chart Document that is sent with the blood (which I know varies from Institution to Institution as far as how much information they require them to complete......and now more of it can be documented in the computer).....there w

 

So when you say "set up product;" are you referring to an Order to perform the Testing (i.e. Type and Crossmatch); or are you referring to the Order to Transfuse?   Because those are 2 different Orders in our Hospital system.  So ALL I want to see are the Testing Orders; not the Orders to Transfuse (after all, does not Nursing make sure they have an Order on the Chart before they give any/all other medications?"  And I am even told that here, not only is it in their protocol to check for a Transfusion Order, but there is something they sign off on (in computer) to acknowledge they "received" the order.

Brenda

 

 

This is how they order in our system:

 

Under Transfuse they select which product they want. The Nursing to Administer is automatically selected along with 0.9% NaCl. They then have to check the Set up [Product] and put in if it's stat/routine, how many units, the reason why. Then the order is electronically signed and submitted. When this happens Nursing gets their order to transfuse and Blood Bank gets a requisition printed to set up whatever product they ordered.

 

The problem we encounter is that the doctor's forget they have check Set Up so Nursing gets an order, but Blood Bank never does. Then Nursing calls asking if the blood is ready and we reply "we never got an order." So we've had some delays in patient care because of that. 

 

as already a statement that said "I HAVE IDENTIFIED INTENDED REIPIENT AND COMPARED THIS WITH BLOOD LABEL AND WITH THE UNIT IDENTIFICATION;"so I am adding to that; AND HAVE CONFIRMED THAT THERE IS AN ORDER TO TRANSFUSE."  There are then 2 spaces for the 2 Nurses to sign and date.

 

Also, 3 things regarding your statement that Inspectors wanted to know how you were making sure Nursing was doing their job: 

 

1.  We do follow units to the floors a few times a year and audit their process

 

2.  By adding to our pick-up slip (which is what we have done other places," a line for the Physician "requesting the Transfusion;"' (or something along those lines), that has been our confirmation; and that is then the Name we enter in the computer when we Issue the Product.

 

3.  I can tell you that in 2 places where our Transfusion Chart Copy Forms were actuallyduplicate, carbon forms, we would get the 2nd copy back for the purpose of auditing completion by Nursing.  At one place, we were cited by the FDA because there were too many incomplete Forms.  I went to Nursing administration and we continued to Audit and return incomplete Forms....which improved the process some, but still not to the extent the FDA wanted....so we were cited the next Inspection again (only this time, the CEO made the Nursing Administrator come to the closing meeting).  Because after all, what else can we do?  At some point, Nursing should be made by "their" Management to follow "their" protocols; and they should audit those protocols.  It just seems to me that the Blood Bank is having to be the gate-keeper for more and more of the Nursing processes.

 

But I have no doubt you feel my pain.....as we all do; so thanks so much for your response!  

Brenda

 

"There was a case years ago here where the state came in to review a surgical case that went bad. Had nothing to do with the Blood Bank, but when they scrutinized this case they told us that now it would be our job to make sure the nurses did theirs. From then on, we get a printout of their order for blood in the Blood Bank and we match it to what goes out.

As you say above, I agree that it's not our place to make sure the order is there. But ever since then even Joint Commission inspectors have asked me "how do your techs in the Blood Bank confirm the order to transfuse?".

Since we made this change we have had 3 or 4 instances where the nurse sent us a request for a second unit of blood for a single unit order that was already complete. Very sad that their carelessness has to become our problem.

Some Blood Banks that do not want to get the actual printed order will put a statement on the request form that is signed by the nurse with items checked off:

Order verified

Consent verified

Pre-transfusion vital signs performed

At least then you are covering your Blood Bank staff if an extra unit is issued; you had a signed document from a licensed RN to back you up.

I feel your pain on this one Brenda.

[Brenda K Hutson]

So what I have come up with to assist "them" in doing "their" job is:

1.  I am revising the Blood Product Pick-Up Slip such that there will be a line that states:  "I have verified that a Transfusion Order Exists from Provider ________; then there will be a line for the signature of the person completing that ______________.  We will not Issue the blood unless that Form is completely filled out.

 

2.  On the Transfusion Chart Document that is sent with the blood (which I know varies from Institution to Institution as far as how much information they require them to complete......and now more of it can be documented in the computer).....there w

 

So when you say "set up product;" are you referring to an Order to perform the Testing (i.e. Type and Crossmatch); or are you referring to the Order to Transfuse?   Because those are 2 different Orders in our Hospital system.  So ALL I want to see are the Testing Orders; not the Orders to Transfuse (after all, does not Nursing make sure they have an Order on the Chart before they give any/all other medications?"  And I am even told that here, not only is it in their protocol to check for a Transfusion Order, but there is something they sign off on (in computer) to acknowledge they "received" the order.

Brenda

 

 

Oohh, I really have to comment here; but hopefully to assist you!  

In 1 of the 5 Hospitals I worked at in another State (my 3rd place), I was shocked when I found that the Tissue Bank resided in the Blood Bank (had never heard of that).  What a nightmare!  I don't know about you, but we stored Tissues at Room Temp., Refrigerator, Freezer (bones, etc.) and even aortic valves in Liquid Nitrogen.  We had to log-in every one of these tissues when they arrived (on cards; and 1 time a Rep. came with a briefcase full for 1 surgery case because they were not sure what they would use); with Name, Size, Checking off boxes that all appropriate Testing had been done, Expiration, and more).  Then we had to sign them out (on the card) when requested; and sign them back in if returned.  Among the many problems were:

 

1.  They often would not know "exactly" what size they wanted, so would request maybe 5 different sizes of the same tissue to be signed out....so of 

     course,  we had to sign all 5 out, then sign 4 back in.

2.  They would call to ask if we had a "such and such;" but would not call it by the name on listed on the Tissue....like we are supposed to know what other

      names these tissues might go by (we were Blood Bankers; not Tissue Bankers)....then they would get mad if we sent the wrong thing; or we would be

      on the phone reading off the name of everything we had to see what they wanted, because they were just sure they had ordered it.

3.  The bones stored in the freezer could not be returned once checked out....they knew that, and we re-emphasized it when they would say they wanted it. 

      But I can't tell you  how many times it would be returned and then the Surgeon would literally scream at us for not being willing to take it back.

 

And, as per your situation, we did it for exactly the same reason (they decided they could not monitor temps. as well as the Blood Bank)!  I am thinking....they can perform surgery, but they cannot monitor temps.??

Sooooooooo....my Medical Director said if I could get data to show the Tissue Bank resided in the OR in most Hospitals, he would back me up.  Now I was living in a large state at the time (Calif.).  I called the State Dept. of Health Services in Calif. and asked them to Fax me a list of "every" Hospital in Calif. that had a Tissue Bank License (it was quite a few).  I then called every single one of those Hospitals and asked if the Tissue Bank resided in the OR, or the Blood Bank.  By far....they resided in the OR.  So guess what; that Tissue Bank is now in their OR; where as far as I am concerned, is the logical place for it to be.  Maybe that will help you?!  

Brenda

 

Here (Michigan, US), we receive an order for a test or product from the hospital system.  Once the product is tagged and available, we call the unit to let them know. 

 

Typically a transporter brings a written order slip when they come to pick up the product.  It includes, among other things, the reason for transfusion, the type of product and the unique BB armband number (that matches the number on the unit tag, specimen used for T&S and armband on patient.)  FDA, JCAHO has never had a problem with these being inadequate for "confirming an order".

 

Indeed, BB here has had to take over functions which you would expect to be monitored by other areas.  Our OR dept. could not handle proper tracking of bone and other transplant tissue, so we have to stock, issue and track it using our BB system.

 

Scott

 

 

This is how they order in our system:

 

Under Transfuse they select which product they want. The Nursing to Administer is automatically selected along with 0.9% NaCl. They then have to check the Set up [Product] and put in if it's stat/routine, how many units, the reason why. Then the order is electronically signed and submitted. When this happens Nursing gets their order to transfuse and Blood Bank gets a requisition printed to set up whatever product they ordered.

 

The problem we encounter is that the doctor's forget they have check Set Up so Nursing gets an order, but Blood Bank never does. Then Nursing calls asking if the blood is ready and we reply "we never got an order." So we've had some delays in patient care because of that. 

 

as already a statement that said "I HAVE IDENTIFIED INTENDED REIPIENT AND COMPARED THIS WITH BLOOD LABEL AND WITH THE UNIT IDENTIFICATION;"so I am adding to that; AND HAVE CONFIRMED THAT THERE IS AN ORDER TO TRANSFUSE."  There are then 2 spaces for the 2 Nurses to sign and date.

 

Also, 3 things regarding your statement that Inspectors wanted to know how you were making sure Nursing was doing their job: 

 

1.  We do follow units to the floors a few times a year and audit their process

 

2.  By adding to our pick-up slip (which is what we have done other places," a line for the Physician "requesting the Transfusion;"' (or something along those lines), that has been our confirmation; and that is then the Name we enter in the computer when we Issue the Product.

 

3.  I can tell you that in 2 places where our Transfusion Chart Copy Forms were actuallyduplicate, carbon forms, we would get the 2nd copy back for the purpose of auditing completion by Nursing.  At one place, we were cited by the FDA because there were too many incomplete Forms.  I went to Nursing administration and we continued to Audit and return incomplete Forms....which improved the process some, but still not to the extent the FDA wanted....so we were cited the next Inspection again (only this time, the CEO made the Nursing Administrator come to the closing meeting).  Because after all, what else can we do?  At some point, Nursing should be made by "their" Management to follow "their" protocols; and they should audit those protocols.  It just seems to me that the Blood Bank is having to be the gate-keeper for more and more of the Nursing processes.

 

But I have no doubt you feel my pain.....as we all do; so thanks so much for your response!  

Brenda

 

"There was a case years ago here where the state came in to review a surgical case that went bad. Had nothing to do with the Blood Bank, but when they scrutinized this case they told us that now it would be our job to make sure the nurses did theirs. From then on, we get a printout of their order for blood in the Blood Bank and we match it to what goes out.

As you say above, I agree that it's not our place to make sure the order is there. But ever since then even Joint Commission inspectors have asked me "how do your techs in the Blood Bank confirm the order to transfuse?".

Since we made this change we have had 3 or 4 instances where the nurse sent us a request for a second unit of blood for a single unit order that was already complete. Very sad that their carelessness has to become our problem.

Some Blood Banks that do not want to get the actual printed order will put a statement on the request form that is signed by the nurse with items checked off:

Order verified

Consent verified

Pre-transfusion vital signs performed

At least then you are covering your Blood Bank staff if an extra unit is issued; you had a signed document from a licensed RN to back you up.

I feel your pain on this one Brenda.

[Brenda K Hutson]

So what I have come up with to assist "them" in doing "their" job is:

1.  I am revising the Blood Product Pick-Up Slip such that there will be a line that states:  "I have verified that a Transfusion Order Exists from Provider ________; then there will be a line for the signature of the person completing that ______________.  We will not Issue the blood unless that Form is completely filled out.

 

2.  On the Transfusion Chart Document that is sent with the blood (which I know varies from Institution to Institution as far as how much information they require them to complete......and now more of it can be documented in the computer).....there w

 

So when you say "set up product;" are you referring to an Order to perform the Testing (i.e. Type and Crossmatch); or are you referring to the Order to Transfuse?   Because those are 2 different Orders in our Hospital system.  So ALL I want to see are the Testing Orders; not the Orders to Transfuse (after all, does not Nursing make sure they have an Order on the Chart before they give any/all other medications?"  And I am even told that here, not only is it in their protocol to check for a Transfusion Order, but there is something they sign off on (in computer) to acknowledge they "received" the order.

Brenda

 

 

Oohh, I really have to comment here; but hopefully to assist you!  

In 1 of the 5 Hospitals I worked at in another State (my 3rd place), I was shocked when I found that the Tissue Bank resided in the Blood Bank (had never heard of that).  What a nightmare!  I don't know about you, but we stored Tissues at Room Temp., Refrigerator, Freezer (bones, etc.) and even aortic valves in Liquid Nitrogen.  We had to log-in every one of these tissues when they arrived (on cards; and 1 time a Rep. came with a briefcase full for 1 surgery case because they were not sure what they would use); with Name, Size, Checking off boxes that all appropriate Testing had been done, Expiration, and more).  Then we had to sign them out (on the card) when requested; and sign them back in if returned.  Among the many problems were:

 

1.  They often would not know "exactly" what size they wanted, so would request maybe 5 different sizes of the same tissue to be signed out....so of 

     course,  we had to sign all 5 out, then sign 4 back in.

2.  They would call to ask if we had a "such and such;" but would not call it by the name on listed on the Tissue....like we are supposed to know what other

      names these tissues might go by (we were Blood Bankers; not Tissue Bankers)....then they would get mad if we sent the wrong thing; or we would be

      on the phone reading off the name of everything we had to see what they wanted, because they were just sure they had ordered it.

3.  The bones stored in the freezer could not be returned once checked out....they knew that, and we re-emphasized it when they would say they wanted it. 

      But I can't tell you  how many times it would be returned and then the Surgeon would literally scream at us for not being willing to take it back.

 

And, as per your situation, we did it for exactly the same reason (they decided they could not monitor temps. as well as the Blood Bank)!  I am thinking....they can perform surgery, but they cannot monitor temps.??

Sooooooooo....my Medical Director said if I could get data to show the Tissue Bank resided in the OR in most Hospitals, he would back me up.  Now I was living in a large state at the time (Calif.).  I called the State Dept. of Health Services in Calif. and asked them to Fax me a list of "every" Hospital in Calif. that had a Tissue Bank License (it was quite a few).  I then called every single one of those Hospitals and asked if the Tissue Bank resided in the OR, or the Blood Bank.  By far....they resided in the OR.  So guess what; that Tissue Bank is now in their OR; where as far as I am concerned, is the logical place for it to be.  Maybe that will help you?!  

 

We have the same 2 systems....but there is nothing in Epic that "forces" them to look in there (i.e. to acknowledge that they have seen the Order to Transfuse); but it is in their protocol.  Are you saying that the Prepare Order is somehow related to the Order to Transfuse....or that it is your Order to perform the Testing (Type and Crossmatch)?  I was told by another Hospital that they had a system in which the Nurse could not even request blood (I think the request came through the computer to the Blood Bank; vs. a separate Pick-Up Form), unless there was an Order to Transfuse.

Brenda

 

We have been using Epic for almost 2 years and Sunquest in the Lab since 2001.   There is the "prepare..." in Epic that translates into a lab order for us to execute.  Then there is the "transfuse..." order in Epic that is strictly a nursing order.  They cannot hang a component in Epic without a TRANSFUSE order which comes from the physician.  We occasionally have them neglect to order the Prepare and call wondering where their component is hours later.  Epic isn't great but an EMR has helped alot.

 

 

Brenda

 

Here (Michigan, US), we receive an order for a test or product from the hospital system.  Once the product is tagged and available, we call the unit to let them know. 

 

Typically a transporter brings a written order slip when they come to pick up the product.  It includes, among other things, the reason for transfusion, the type of product and the unique BB armband number (that matches the number on the unit tag, specimen used for T&S and armband on patient.)  FDA, JCAHO has never had a problem with these being inadequate for "confirming an order".

 

Indeed, BB here has had to take over functions which you would expect to be monitored by other areas.  Our OR dept. could not handle proper tracking of bone and other transplant tissue, so we have to stock, issue and track it using our BB system.

 

Scott

 

 

This is how they order in our system:

 

Under Transfuse they select which product they want. The Nursing to Administer is automatically selected along with 0.9% NaCl. They then have to check the Set up [Product] and put in if it's stat/routine, how many units, the reason why. Then the order is electronically signed and submitted. When this happens Nursing gets their order to transfuse and Blood Bank gets a requisition printed to set up whatever product they ordered.

 

The problem we encounter is that the doctor's forget they have check Set Up so Nursing gets an order, but Blood Bank never does. Then Nursing calls asking if the blood is ready and we reply "we never got an order." So we've had some delays in patient care because of that. 

 

as already a statement that said "I HAVE IDENTIFIED INTENDED REIPIENT AND COMPARED THIS WITH BLOOD LABEL AND WITH THE UNIT IDENTIFICATION;"so I am adding to that; AND HAVE CONFIRMED THAT THERE IS AN ORDER TO TRANSFUSE."  There are then 2 spaces for the 2 Nurses to sign and date.

 

Also, 3 things regarding your statement that Inspectors wanted to know how you were making sure Nursing was doing their job: 

 

1.  We do follow units to the floors a few times a year and audit their process

 

2.  By adding to our pick-up slip (which is what we have done other places," a line for the Physician "requesting the Transfusion;"' (or something along those lines), that has been our confirmation; and that is then the Name we enter in the computer when we Issue the Product.

 

3.  I can tell you that in 2 places where our Transfusion Chart Copy Forms were actuallyduplicate, carbon forms, we would get the 2nd copy back for the purpose of auditing completion by Nursing.  At one place, we were cited by the FDA because there were too many incomplete Forms.  I went to Nursing administration and we continued to Audit and return incomplete Forms....which improved the process some, but still not to the extent the FDA wanted....so we were cited the next Inspection again (only this time, the CEO made the Nursing Administrator come to the closing meeting).  Because after all, what else can we do?  At some point, Nursing should be made by "their" Management to follow "their" protocols; and they should audit those protocols.  It just seems to me that the Blood Bank is having to be the gate-keeper for more and more of the Nursing processes.

 

But I have no doubt you feel my pain.....as we all do; so thanks so much for your response!  

Brenda

 

"There was a case years ago here where the state came in to review a surgical case that went bad. Had nothing to do with the Blood Bank, but when they scrutinized this case they told us that now it would be our job to make sure the nurses did theirs. From then on, we get a printout of their order for blood in the Blood Bank and we match it to what goes out.

As you say above, I agree that it's not our place to make sure the order is there. But ever since then even Joint Commission inspectors have asked me "how do your techs in the Blood Bank confirm the order to transfuse?".

Since we made this change we have had 3 or 4 instances where the nurse sent us a request for a second unit of blood for a single unit order that was already complete. Very sad that their carelessness has to become our problem.

Some Blood Banks that do not want to get the actual printed order will put a statement on the request form that is signed by the nurse with items checked off:

Order verified

Consent verified

Pre-transfusion vital signs performed

At least then you are covering your Blood Bank staff if an extra unit is issued; you had a signed document from a licensed RN to back you up.

I feel your pain on this one Brenda.

[Brenda K Hutson]

You could add a space to the pick-up Form for the Ordering Physician....that might help remind them to look for the Order to Transfuse; as well as allow you then to enter the Name of the Physician who Ordered the Transfusion (which may be different than the one that ordered the Type and Crossmatch).  Also, we send incomplete pick-up slips back to the floor for completion before we will hand out any Product.  What I learned (after 30 years) is that the more you are willing to do Nursing's job; the more they will let you do it (so they don't complete the form; and they just get a phone call and are verbally asked questions; but that is extra work for you).  

Just some thoughts....

And thanks so much for your reply!

Brenda

 

We were receiving a photocopy of the physician's orders from the chart, along with a photocopy of the consent form for every pickup.  (Product orders print out on the Blood Bank printers when ordered.)  It worked well for everyone but ER, who had a different computer system for order entry that they "could not" get copies of, so they asked to be exempted from the orders requirement.  Now that we are getting to an Electronic Medical Record (EMR) setup for the rest of the hospital, we were told that the RNs could no longer give us a copy of the Dr's orders at pickup from the system without getting a whole chart printout (yikes!).  (Others have said they could do a single screen print, but most don't know that.  Supposedly, the ER is capable of that too, but they never picked up on it either.) 

 

So...in order to get the whole thing to work around the clock, we had the RNs go back to just bringing a small pickup form that identifies the pt, the BB ID band number and which product they want at the time.  They also still bring the copy of the consent form.  Annoyingly, many are still bringing the pickup slip without any product checked on it.  Since the employee picking up is frequently not the individual hanging the unit, we have to call and ask what they want the person to pick up.  If we wanted to see the orders, we would have to go into the computer (HCA Meditech 5.6.6) and find them.  I resisted that on the basis that we still would not know what they wanted to pickup at any one time, but many times I can't get that from a simple checkoff form either! 

 

The EMR has made getting the patient's orders more difficult for us and the RNs.  They had to build the transfusion orders on the product orders (so we do see some of them) so the RNs had some idea of when and how the Drs wanted the products given, but because the Dr's also wanted a "HOLD" option, they then had to build a separate TRANSFUSE order if they changed from Hold to Give (those we don't see). 

 

Our recent Joint inspector seemed happy and did not mention "how do WE know the RN has an order to give", so we are not checking that (yet!).  Maybe it is a personal thing with some inspectors.  I think that should be a Nursing responsibility and I think our RNs are double checking the order as they double check the unit(s) at the bedside before they hang them.

[Brenda K Hutson]

Wow...sorry everyone; guess I have not replied to responses since this website changed and I see I made a mess of it!  Was trying to respond to people's individual posts...

Brenda