On 10-6 we had a chemo patient admitted thru ER. The ER doc ordered to units of pc and a plateletpheresis. Both the hospitalist who wrote the H&P (electronic only) and the oncologist consultion (electronic only) stated the patient was in a experimental protocol at Stanford and was to get irradiated leukoreduced blood products (all our products are leukoreduced so this wasn't an issue). Neither of them wrote this on the patients chart and nursing does not have access to the electronic reports. Friday evening the oncologist writes on the patients chart that all blood products are to be irradiated. By this time the patient has ahd 4 units of packed cells and 1 plateletpheresis. The patient was transfered to Stanford the following day. I don't think this is reportable as we never had the order for irradiated blood products until after the transfusion. What do you think?

Not reportable since you did not err, unless YOU practice Medicine. I would think an internal quality variance should be initiated . . .

On 10-6 we had a chemo patient admitted thru ER. The ER doc ordered to units of pc and a plateletpheresis. Both the hospitalist who wrote the H&P (electronic only) and the oncologist consultion (electronic only) stated the patient was in a experimental protocol at Stanford and was to get irradiated leukoreduced blood products (all our products are leukoreduced so this wasn't an issue). Neither of them wrote this on the patients chart and nursing does not have access to the electronic reports. Friday evening the oncologist writes on the patients chart that all blood products are to be irradiated. By this time the patient has ahd 4 units of packed cells and 1 plateletpheresis. The patient was transfered to Stanford the following day. I don't think this is reportable as we never had the order for irradiated blood products until after the transfusion. What do you think?

Not FDA reporable but it needs to be reported back to Physician at your facility and back to Stanford and I agree it needs internal review. GVHD can be treated/managed after the fact (i.e. steroids) but prevention is still the best.

Leukoreduction has been accepted as CMV safe. As far I know it has not been accepted to replace Irradiation.

I was hoping someone would think it was reportable becuase I was very unhappy with this MD. All they need to do is have their office fax me an order when they have patients with special needs and I can put a marker in the computer. I turned it over to our QI department.

You can always report it . . . but I think you did the correct thing - it is definitely a quality issue.

I agree with David; you "don't know what you don't know". The physician should have communicated it. Maybe your Transfusion Committee could send this physician a letter?

It has gone to our Quality Improvement department. Our pathologist is involved in these reviews. In some ways it is easier when the problem is at our end as I have direct input in the corrective action.