Request forms

[YorkshireExile]

Is it a requirement by CAP or AABB standards that all blood bank specimens must be accompanied by an actual manual paper request form for tests such as Type and Screen or Type and Crossmatch? I always thought it was, but now I`m not so sure. The form could be computer generated when the doctor places the order. Previous hospitals I have worked in insisted on this so we could compare the details on the form with the details on the specimen, but if you have a good computer system where you can see all the ordering details for checking, is an actual paper form  really necessary?

 

My current hospital wants to reduce paper forms (well, remove them altogether)  and if I want to keep for blood bank I need documentary evidence to prove why I need forms or evidence that accrediting bodies require forms.

 

So forms or no forms with BB specimens?

Edited July 7, 2015 by YorkshireExile

[goodchild]

If your computer system captures and retains all the information you would need, why would you need a form?

[tbostock]

No form needed. The specimen label has the name of the test "type and screen" on it. And we can see all the details in the EMR, including the name of the collector.

[Auntie-D]

In the UK we have a requirement for a form as the form and sample both need signing by the person who took the sample (not the person who put the request in) - and you can't scan a sample...

[Malcolm Needs ☆]

But you CAN accept electronic request forms, as there is an electronic audit trail on the computer that will show who ordered the cross match (or whatever) and whether they had the right to so do.

[Auntie-D]

But you CAN accept electronic request forms, as there is an electronic audit trail on the computer that will show who ordered the cross match (or whatever) and whether they had the right to so do.

 

But it's about who is taking responsibility for the sample, not the request.

[goodchild]

By your own logic why do you need the form then? Can't the electronic record have a field for who takes responsibility?

[YorkshireExile]

Thanks for all the replies. So it seems in UK a form is needed to be sent with the specimen, but in USA no form is needed. Is that okay with CAP and AABB?

[Malcolm Needs ☆]

No YorkshireExcile, that is not correct, despite what others may say.

 

A form IS needed in the UK (to be in line with BCSH Guidelines), but there is absolutely NOTHING in the BCSH Guidelines that prohibits an electronic form, as long as there is an audit trail to show that the request has been made by someone who has the authority to make such a request.  There IS a need for the sample to be signed and dated by the person who has taken the blood sample, but this does NOT mean that they are the same person that has authorised the order in the first place - otherwise we could not use the good services of phlebotomists.

[Auntie-D]

By your own logic why do you need the form then? Can't the electronic record have a field for who takes responsibility?

 

We already do this with the use of a sample taker pin number. We also insist on the PIN and signature to be hand written - we find about 5% of forms coming down have a different handwritten PIN and name/signature to the printed one. Presumably from people leaving themselves logged on a terminal by accident. The other alternative is people sharing login passwords - totally against hospital policy but it happens. Insisting on handwritten signatures eliminates this --and also gives us a way of identifying which buggers are breaking the rules--. Without the handwritten signature we would never know...

[SMILLER]

Eh?  I am in the US, and typically a physician orders the test on the hospital system and we draw it and run and report it just like any other test. The only "form" we have is the label that goes on the tube. The collector initials the tube (just like any other) and the info on the tube is all entered into the BB system.  Not sure what the big deal is.

 

We do require forms for histology specimen work (biopsys or whatnot), but that is because the have to enter alot of info on each case into their system themselves.

 

Scott

[Auntie-D]

 The collector initials the tube (just like any other) and the info on the tube is all entered into the BB system.  Not sure what the big deal is.

 

 

The issue is that you do not have proof that you can store for the required timefram of this - unless you can somehow scan and store the sample tubes? In a litegous society the sample taker could just say that the laboratory inputted the details wrongly.

 

It's all about full traceability and people legally taking responsibility for their part in the process.

 

Due the large amount of (potentially fatal) WBIT incidents, surely a definitive, permemnt record of who took the sample is essential?

 

Anyone not recording this information may find it come to bite them on the bottom if they get asked to stand up in court.

 

The UK are much more stringent about this as any court payouts come out of the public pot as we no longer have Crown Indemnity in the NHS.