We do not deal with many traumas at my hospital but we recently had a trauma situation in which the patient got 6 units of uncrossmatched type specific blood. We had the doctor sign an emergency release form stating that "routine crossmatch procedure has been omitted under my responsibility" the physician signs and dates, the tech signs and dates, and the unit numbers are listed along with expiration dates. During routine transfusions we complete a manual form where part is filled out by BB tech when nurse picKS up blood from blood bank, nurse and tech both sign, then form is taken to bedside where unit is checked with another nurse and both nurses sign, then all vitals and times are recorded on this form and the original goes on chart and a copy is sent back to BB. This form was not completed during this emergency release trauma. My question is, do we need to try to complete these forms for each unit now after the fact? Or is the emergency release form sufficient? What is the minimum paperwork required? Thanks.

We have an emergency release form that they sign.  We also send an attached Blood Administration form as you mentioned above.  It almost always comes back blank, especially if multiple units are transfused quickly.  They do have those patients on continuous vital sign monitoring, so I'm not as worried about that as I am about having my 2 nurse signatures.  Although they are always uncrossed type O units, so it's the best choice they have at the moment.

So...yes, an inspector would say this needs to be completed, but sometimes you just have to save the life first.

Our tags have a section that can be checked and signed indicating that there was a rapid transfusion., and that vitals can be found on the chart.   Someone still has to review the tag and send the copy back to BB.

 

Scott

Agree with Teri.  And I've spent many hours chasing after RNs and MDs to get the appropriate forms signed, even if it's retrospectively.

 

In the EHR world where I live now,  I have created an "Emergency Release" electronic order that states all the appropriate stuff.  Once signed electronically by the MD you can retrieve it from the chart if an inspector asks.

Thanks for the replies.

Likewine99 what is the "appropriate stuff" that you are referring to?

Agree with Teri.  And I've spent many hours chasing after RNs and MDs to get the appropriate forms signed, even if it's retrospectively.

 

In the EHR world where I live now,  I have created an "Emergency Release" electronic order that states all the appropriate stuff.  Once signed electronically by the MD you can retrieve it from the chart if an inspector asks.

 

I love this idea of documentation when they order electronically!  This is something we'll have to look into for our facility.