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Thank you, everyone, for your responses. You have all corroborated my interpretation of the CAP requirement. I will be following up with CAP, as Quality Guy suggested. I will post with CAP's answer!

Cool. Since we are gearing up for an upgrade from Version 3.8 to 3.11 Quite a big jump and I never got trained on the guts of this BB system they are going to ask to have someone from a build team come and help us. So I'm definitely going to see if I can incorporate QC !

yay pens!

I added tests to result QC results, Lot # and Expiration date to our FHB battery, as well as our KB. They are free text fields. This way these are all documented at result entry and are filed with the specimen results.

Believe it or not, we were doing the same thing, until I was doing our self inspection and the CAP checklist just listed it as quarterly, as well as the manufacturer's recommendations. So I took it off our daily maintenance. So unless your equipment manual states that it has to be done daily (because CAP states you have to do manintenance as often as the manufacturer recommends it), quarterly is just fine!

The Echo/solid phase is very sensitive for Rh antibodies. Just thinking out loud here (so to speak)... Did he receive (a large volume of) fluids between the time the two samples were drawn? If so, an antibody with a low titer might be diluted in the second sample and no longer detectable, whether allo- or auto-. Is the variability of reaction (1+ to 3+) consistent with the ID panel donor type? - in other words are the R1 cells reacting less strongly than the R2 cells or are the reactions variable without regard to the donor type.

Tap water changed every week, no additives

A little late on this subject but I thought I would chime in anyway. We suffered the same problem as you described a few years and 2 employers ago. When trying to determine what to do about it we discovered that the nurses were being "required" to document the same information in multiple places. This made no sense so I worked with a team from the nursing department and we came up with a system that only required the documentation in a single place and did away with the other locations. An example is that they were being required to document vitals both in the patient's chart and on the transfusion record. Obviously they were much more in tuned to documenting this info on the chart so we removed it from the transfusion record. Any inspector who wanted to see the info was shown the chart. Over the years I have discovered that simplifying a process usually enhanced it.

Wow, that's a problem. However, being cited may not be such a bad thing in the long run. As blood bankers, we like to be perfect and those hits are painful. But they can be turned into a great weapon. I was getting nowhere with nursing education for recognition of transfusion reactions until CAP cited me for it. After that, the earth moved, and not only do we have that education piece, but lab has input. Chin up and soldier on!

What Malcolm said! The wouldn't get away with it if it was Morphine... I've PM'd you ours anyway though.

If the information is required, then it is required. If the nurses can't be bothered to fill it in, go down the disciplinary route. If the information is NOT required, then ditch that bit of the form.