Some of us do, Mabel. I worked from 7 AM to 630 PM, met my wife for dinner, went home, walked the dog, answered my email, and I am headed back to the lab right after this to make some specimens for my students to work up when they come in. I think I am going to give them a warm auto with an underlying anti-e. That should keep 'em busy for a couple of hours.

BC

That is truly evil! I've been accused of enjoying student torture too much, but that tops me...keep up the good work!

rcurrie, you are my new hero! The worst I have done is add a little of all the antisera I have in house.... that is about 10-12 antibodies. You must send me your method for making up those lovely student specimens. I have a new crop coming in the fall.

When our checklist was made, I went down the Nursing procedure item by item. Their protocol and the checklist need to correspond to be effective. Our facility transfuses 250-300 units per month and I perform 1 audit per month by rotating between the areas.

Uh-OH, I haven't done the May audit yet. Better get a move on!...

AABB Technical Manual under Quality Systems - Blood Utilization Assessment it states:

To "investigate" (taken to infer audit) 5% of the number of "cases" (transfuison) occurring within a defined time frame(detremined my each facility) or 30 cases min, whichever is "larger"

But you will find we all have difficulty with the volume. If i followed this I would have to do 40 a month and most of us do not have the staffing to do this. So we set a numer greater than 30 which is required to do per year

[ATTACH]320[/ATTACH]

I hope I did this right. I have included an attachment of a copy of my transfusion audit form, I have had

many requests for.

If it does not open: I can be reached at ellie.ross@providence.org

Transfusion Audit Form .doc

Example of audit checklist (ISO15189)

QASOP013 att 6.4.doc

For anyone interested:

I put my checklist in the Document Library under Audit Checklist.

Brenda Hutson

nice list of documents - but I couldn't find this one in the library - did it not "stay" or something?

I'm curious if any of the audits include units that were given in surgery. Our forms that we receive from the floor after a transfusion has been given is supposed to be filled out completely with time, date, who verified, etc. but the ones from surgery come back with "See anesthesia record". Does any other place accept this as appropriate? We don't like it but haven't gotten anywhere in changing it.

OR here uses the same documents as the other nursing areas. This makes for an easier transition if a unit is hanging when the patient goes to surgery and if a unit is hanging when the patient returns to the floor after recovery. Seems to work well for us.

Edited June 5, 201015 yr by Deny Morlino
clarification

nice list of documents - but I couldn't find this one in the library - did it not "stay" or something?

Sorry, I did not realize that until now. I will try again next week.

Brenda

the ones from surgery come back with "See anesthesia record". Does any other place accept this as appropriate? We don't like it but haven't gotten anywhere in changing it.

Our Anesthesists do exactly the same at our institution (ie: write "See anesthesia record" instead of documenting all the vitals on the blood transfusion form.) I can see how it would be cumbersome for the anestesists to write all that info in both their records and the blood form, especially during major surgeries using a lot of blood. As long as they document the "time started" and "time stopped" and keep meticulous anesthesia records, we are comfortable with it.

Our Anesthesists do exactly the same at our institution (ie: write "See anesthesia record" instead of documenting all the vitals on the blood transfusion form.) I can see how it would be cumbersome for the anestesists to write all that info in both their records and the blood form, especially during major surgeries using a lot of blood. As long as they document the "time started" and "time stopped" and keep meticulous anesthesia records, we are comfortable with it.

We have an extensive review procedure, but O.R. does not participate either in the pickup requirements or the transfusion documentation form (even though they get the same form as the rest of the hospital). When we started our new procedure, it quickly became obvious that it did not just fit their needs or procedures, so mostly they just document "see anesthesia notes..." We are living with it.

We have a check box on our transfusion record for OR to use that says "transfused in OR, see anesthesia flowsheet." There is no reason to require them to duplicate the records. The anesthesia records that I have reviewed have been meticulous...far better than anything the floors put on our form. I have no problem with using their records, particularly since they cheerfully make them available when I ask.

We have a check box on our transfusion record for OR to use that says "transfused in OR, see anesthesia flowsheet." There is no reason to require them to duplicate the records. The anesthesia records that I have reviewed have been meticulous...far better than anything the floors put on our form. I have no problem with using their records, particularly since they cheerfully make them available when I ask.

When this has come up in various places I have worked (in that the Nursing units would want to use the same reasoning; that the vital signs, etc. were already documented on the patient's chart so why should they duplicate this), we found that the parameters used outside of the Transfusion Service did not match recommended Blood Bank Standards (i.e. frequency of taking vital signs during the transfusion; etc.). Using that we were able to require that the OR document on our Form. However, in my current job, we don't have a copy of any record that comes back to us after the transfusion so all documentation is on the patient's chart only.

Brenda

we do 4 a month.

try to do each component if possible.

We allow the "see anesthesia record" and like adieiscast, their records are meticulous.

So long as the clinical notes of the anaesthetist have been critically assessed at audit, are clearly referenced in the audit, and could easily be found by an external auditor who would concur with the sudit findings then there is no problem. Like others here, I find anaesthetists are meticulous in their recording of patient status throughout any procedure.

Cheers

Eoin

Regina,

I am in the same situation. We currently perform very few audits and only have minimal Nursing involvement. Can you also send your checklist to me? Thanks!

Christy Hunt

christy.hunt@crozer.org

I would like a copy of check list. It seems like a very good tool

Thanks

EG

gillise@nmhct.org

We have a 16-point checklist that the Med Techs use - it has been a good thing to involve the bench techs as it 1) helps develop them as future leaders and 2) helps build a bridge between the blood bank staff and the nursing staff.

We transfuse roughly 10,000 products per year in a 400-bed hospital. We audit about 30 transfusions a month; we do so many per floor/unit based on the average number of transfusions each unit does per year.

In fact, one of our AABB inspectors was so pleased with the tool they didn't even wish to see a transfuion while they were here.

I would be happy to share our checklist.

Regina,

I would like to have a copy of your checklist.

Thanks.

aafrin

adil.elavia@jehangirhospital.com

Dear Regina

I would like to have a copy of the checklist please.Thanks in advance

regards

rema menon(drrema_m@apollohospitals.com)

We have a 16-point checklist that the Med Techs use - it has been a good thing to involve the bench techs as it 1) helps develop them as future leaders and 2) helps build a bridge between the blood bank staff and the nursing staff.

We transfuse roughly 10,000 products per year in a 400-bed hospital. We audit about 30 transfusions a month; we do so many per floor/unit based on the average number of transfusions each unit does per year.

In fact, one of our AABB inspectors was so pleased with the tool they didn't even wish to see a transfuion while they were here.

I would be happy to share our checklist.

would you please share it with me, too? please send it to my email nsfirm@yahoo.com thanks before

nova

I think transfusion audits present a tremendous opportunity for "teachable moments" and to build relationships with the clinical staff. I would aspire to do a certain number of audits a month rather than just set aside time, because when things go to hell in a hand basket in the blood bank the audits go away. With regards to involving nursing staff, I feel very strongly that this should be a shared responsibility, ideally with a med tech and a nurse educator working shoulder to shoulder. In order to be effective and sustainable, nurses need to feel a sense of ownership.

We do monthly audits and we also hand out 10 to 15 self-audits a month. The transfusing RN checks off the same items that we audit and returns the self-audit to the blood bank (we get almost all of them back). We have had a number of nurses tell us that they were helpful and that way we get more opportunities per month than we would have time to actually observe.

.....

In fact, one of our AABB inspectors was so pleased with the tool they didn't even wish to see a transfuion while they were here.

I would be happy to share our checklist.

Regina, your post has survived time!! I, too, have 10,000 units a year and 30 audits a month and am most interested in your checklist as it warded off the AABB inspector!!! If you are willing to kindly share it: ek01@aub.edu.lb.

Thank you!!