TRM.41350 states that if a patient has special transfusion requirements they must appear on the transfusion tag.
Our facilities utilize the transfusion requirement section in various ways and many of our transfusion requirements are not associated with an attribute (for example, transfuse with group O RBC, transfusion with group AB plasma).
How are you planning to achieve compliance with this CAP requirement? Will you print all active transfusion requirements on the tag or will you limit the printing to requirements associated with an attribute?
Thank you in advance for your insight!
Maureen Slackway, MS, MT(ASCP), CPHIMS, CQA
The 2017 revisions were released this week. The computer crossmatch section was revised to align with the FDA guidance.
"If ABO typing discrepancies exist, you should not rely on a computer crossmatch.This is particularly important if there is mixed field red cell reactivity, missing serum reactivity, or apparent change in blood type following hematopoietic stem cell transplantation.Under those circumstances, your procedures should provide for compatibility testing using serologic crossmatch techniques."
I called CAP to verify that this included resolved ABO discrepancies. Our hospital had been allowing computer crossmatches for ABO discrepancies that are resolved, and I'm not sure that our BB LIS could prevent a patient with a resolved ABO discrepancy from receiving a computer crossmatch.
Does your LIS prevent computer crossmatches for patients with MF reactions or weak reverses?
By Sherie Bruns
Do the Blood Bank refrigerator and freezer have to be externally monitored outside of the blood bank? The lab is staffed 24/7 and able to respond to the freezer or refrigerator alarm. Does security or the Emergency Department have to also externally monitor these alarms? Are there any CAP or AABB standards, or does the FDA require this? Just wondering since it seems to be redundant, and we have an older freezer which may be difficult to hook up.
I need some guidance! I did a quick search of the forums for any discussion about this, and the most current posting was in 2010. I'm wondering if anyone has any new information, new experiences, or any advice about CAP TRM.40120. The note states "...all analysts participate in QC on a regular basis."
How frequently is "regular"? For example, when I was looking to complete our annual Competency assessment in September (don't ask...), I was looking for evidence that each individual who performs MTS testing had performed MTS QC. There were some employees who had not performed MTS QC yet in 2016. I'm inclined to say that someone who hasn't performed QC in at least 8+ months is not participating in QC on a regular basis. Being new to my role, I'm just not sure how the assessors interpret this standard, and how others provide evidence of compliance.
My interpretation of these two standards is that eye protection must be made available and instruction on proper use must be given to all the techs. But not that goggles/glasses must be worn at all times in a clinical laboratory regardless of the risk of splash/spatter/aerosol formation.
Do your facilities require that techs wear eye protection at all times or only when performing tasks that have a high risk for exposure? Thanks!
GEN.74100: Appropriate personal protective equipment (gloves, gowns, masks and eye protectors, etc.) is provided and maintained in a sanitary and reliable condition in all technical work areas in which blood and body substances are handled and in circumstances during which exposure is likely to occur.
GEN.74200: Personnel are instructed in the proper use of personal protective clothing/equipment (e.g. gloves, gowns, masks, eye protectors, footwear) and records are maintained.