Do you do live audits of transfusions?

[Karrieb61]

HI all, if I put this in another section on the Forum, I am afraid I won't get any hits. So- I have the standards in front of me and don't interpret the section on Assessments to mean that we have to observe (audit) a transfusion directly. Is this your take on the standard 8.1 and 8.2? We got a deficiency during our last AABB inspection because we didn't audit annual competencies of the nursing staff (huh??) for transfusion but that's another story. In the meantime, I do a very active review of almost 100% of the returned transfusion forms to see what was documented. But does Standard 8.2 mean I am supposed to also audit transfusions in progress? Thanks

[tbostock]

Yes, we do one audit per month.  We follow a transfusion from order to the end of transfusion.  We go upstairs and watch the start of the transfusion and ask the nurse a series of questions.  Any deficiencies are communicated to the nurse manager, but we do not provide the transfusing nurse's name.  We want it to be educational and not perceived as a punitive exercise.  Obviously if it was a glaring error or something dangerous, I would follow up appropriately.

[BBCLS]

Yes, a nurse auditor does this. The nurse auditor come to blood bank and follow the order to the end of transfusion.

[Cliff]

We do the same as tbostock, except every two weeks.

[wellspl]

We are to do a Blood Administration audit quarterly.  Pretransfusion, patient and componenet identification, administration techniques and monitering, and dispostion. 

 

  We  do audits of the returned transfusion tags, and transfusion consents also.

[goodchild]

I don't do as many as I need to but I do set out to do several a quarter.

 

For me the problem is timing; I can't schedule a blood transfusion on the appropriate floor/department when I have a space available in my calendar. Trying to get anyone else to do one is difficult at best. For reasons like this I recommend that your quality plan is realistic when it lays out how many you perform.

Edited September 29, 2014 by goodchild

[kate murphy]

We also do this, but not in response to 8.2.

I think your assessor interpreted the standard.  It does not state that you need to observe.

You need an audit for 'patient identification' but that also includes specimen collection.  'Blood admin policies' need to be audited.

If you have a way to effectively audit all the points listed in 8.2, then I would say that you meet the standard.

[Likewine99]

One of my previous jobs we did it just like tbostock.  Just picked one tx at random, once a month.  We tried to cover all nsg divisions and all shifts if the off shifts had time to follow a unit to the floor.

 

Followed up with nsg director and if we noted any non-conformances we used these as "teachable" moments, tied to pt safety of course and had it outlined in our quality plan

[David Saikin]

I used to do this (for about 7 yrs) but the audit invariably demonstrated 100% compliance every time so we dropped as a monitor.

[AuntiS]

We do this several times a year as well.  But like David says, above, we get 100% compliance each and every time.  So, is there something else you do instead? 

[AMcCord]

We are currently following each of our phlebs to the floor for 2 blood bank draws a month (I have helpers - thank goodness!). I'm also supposed to follow 20 units up to the floor every month (says my lab director), but I can't get anywhere close to that number. I manage to get 1 to 3 done monthly. I'm interested to see that Terri and Cliff say one a month, at hospitals much bigger than mine - I'm going to try that out the next time I sit down to discuss it with my director. I do document the ID of the patient (by visit number) but report to nurse managers in a general way as Terri does. Phleb ID is documented so we can make sure that they are getting their required observations done. We counsel phlebs immediately (privately, of course) to make sure that any deficiencies are corrected in a timely manner.

[ChrisH]

We are a fairly small hospital, with only one full time BB Tech (me), we do one audit a month.

[CMCDCHI]

We do the same as tbostock as well.  We do not always get 100% compliance though, mainly on the "How often do you need to monitor your patient" question.  There is a perception that once an hour is OK though our policy says every 30 minutes.  

[Karrieb61]

Sorry for the delay in responding. I used to work at a much larger institution and I aimed for 3-4 per month. We always got 100% compliance but I still felt it was a way to keep the Blood Bank's face in front of the nursing staff. I monitor quite a bit of paper retrospectively and hope that it will be enough for the next assessment. Trying to get up to the floors here is difficult. Anyway, thanks everyone

[David]

We also do one a month, locations chosen randomly.  Last month the tech doing them happened to go to a unit leased to a long term acute care facility.  Issues began when the administering nurse identified the unit as a 'zero positive' and headed south.  After I filed a variiance report for another one of the events, the nurse manager called me, very incensed, mainly because we invaded her turf to do an audit without her permission.  Apparently the 'unannounced' inspection idea hasn't come to LTAC's yet.  Congratulations to you who always have 100% performances.

[kirkaw]

We do do 'live' transfusion audits, but I agree with Kate, that I do not think this is mandated by AABB standard 8.2. I too find, that my nurses are 100% compliant. Our current audit process involves following transfusion practice from blood (specimen) collection, through testing and transfusion. I have a form that I use to check off each step.

However, I attended the AABB annual conference and went to a wonderful seminar on internal and external audits. One thing they pointed out, was to check all QC and inventory records from the day of the transfusion that is being audited. We haven't ever checked everything that could have affected the transfusion. The advice was, if you have 100% compliance then either the audi is not effective or you are missing something.

There was also talk about having a variety of audits and a schedule of audits that is approved by the medical director. I plan on trying to revamp our quality assurance program to include audits on adverse events, on suppliers and on transfusions adhering to (or not adhering to) the institutions transfusion guidelines.

[tkakin]

I do a live audit, and would say most of the time all is well.  2 times I have observed staff that had literally no idea what they were doing, it was frightening.  My form does not include the  competency of the staff only if the checks were made, and with help the checks were made.  We do 2 observations per floor per year.  It is very difficult to observe at remote sights, I am going to have to look to out source the observations at those sights.

[Karrieb61]

A belated thanks again to all of you. I don't interpret the standard to require me to follow a transfusion although I used to do it often elsewhere. I am ramping up our QA program in the BB to include live audits of patient identification during draws at least. I l already check close to 100% of all returned transfusion admin forms for compliance to signatures, vital sign recordings etc so I think we'll be good come AABB 2015

[Everett9239]

I do live audits, but it appears that we are doing quite a bit more than everyone here.  Is there an established guideline, or a percentage of how many you should be doing to be statistically relevant?  We struggle with getting enough audits performed, but I am wondering if there is a magic number?

[Karrieb61]

Everett, I don't think there is an established guideline for this at all. I think, based on previous inspections I did years ago, that you would want a Blood Bank to show awareness of the need to audit and a written program that says what you audit with a general statement of "several from each floor per year" something like that. You don't want to have to meet your own requirement of X number of live audits per year if you can't reasonably make them happen but you should have a general statement about doing them throughout the year on all floors that transfuse on first shift, whatever. Very vague I know but I think that good intent is the key here with some records to show the inspector/assessor periodically.