My first CAP inspection as Blood Bank Department Head last spring was going great until the part where they follow the unit to observe nursing starting the transfusion. At that point it went all bad fast! My question is what are the consequences if that should occur again? We use Meditech and recently implemented the TAR electronic record but I am still seeing a lot of non-compliance with nursing. And, unlike the Lab, they do not write up and counsel the nurses when the problems are listed. My Administrator is anxious to bring them into line and has asked me to find out what could happen if things still aren't at an acceptable level by the next inspection. Any comments or suggestions are welcome!

Thanks!

Jennifer

Welcome Jennifer,

The Medical director should take it to the chair who will take it to the Medical Board. The CNO is there. This is extremely important.

The consequences are that you will be cited and givien the opportunity(ies) to correct the deficiency. I am looking forward to the same when my CAP occurs (very soon). Nursing compliance with the documentation is poor.

Here the Nursing Department is one of the best, that was not true before. Now, they are really into training, and competency. Then they fill out a lot of paperwork, because if they do not document it, it means they did not do it. Most importantly they are accountable and take ownership of the blood unit once it leaves the dear ol' Blood Bank. There is an incredible organization scheme with preceptors, Nurse Managers, educators etc....

Ask for it, you should get it. As Dave said, once you are CAP cited and it is their fault then they have no choice. But more importantly you do not want a sentinel event, patient safety comes first.

We started doing random transfusion audits that are reviewed monthly by Quality Management, Transfusion Committee and Nursing Leadership. It has helped a lot!

Do jyou use your CAP inspection as part of your JCAHO accreditation? If so, nursing is out of compliance with JCAHO. Remind nursing management of this when you and your medical director meet with them. That is more likely to get their attention, then if they think they are just causing trouble for the Blood Bank.

Phase II deficiencies must be corrected and what you are talking about would fall into that category. As Liz pointed out, it IS a patient safety issue, which is something nursing service should understand. I collected data on transfusion documentation for several months, documenting the types of errors and the frequency of those errors. That information went to the Nursing Council, Quality Management and the Transfusion Committee. The high percentage of errors and omissions started to get their attention. I also found a couple of transfusions which were investigated as reactions that had so many errors in documentation and following SOP that even the most resistant member of nursing leadership had to admit there was a serious problem. Once we received the phase II deficiency, which had to be corrected, they were ready to work with us to change things. Nursing service has an annual education requirement for transfusion policy and recognizing transfusion reactions. I helped with some of the early education segments and always make myself available to answer questions.

DogLover is right. If your hospital happens to be inspected by Joint Commission, you have a big stick to wave. CAP has 'deemed status' for lab inspection. In other words, Joint Commission looks at your CAP lab inspection records. If CAP says your lab is OK, then the Joint Commission accepts that report and does not do a further inspection (at least not an intensive one). If you don't pass Joint Commission, you don't get Medicare money - that would get the attention of the administration. That's my big stick and it works well. Nursing service is all about making the Joint Commission inspectors happy.

Establish some contacts with the right people in nursing leadership and education. Sit down with them and explain what you need and why you need it (think safety, safety, safety). Nursing service has a different point of view than lab, so they need to be able to see the problem in a new way. There may also be a 'turf' issue - they may think that you are messing in their business. They need to see that lab and nursing service are part of the team that is going to make sure patients receive safe transfusions. That's the best way to get their cooperation. Takes time, but it's worth it. Makes like so much easier down the road. If that isn't working well for you, then haul out the big stick - regulatory compliance and risk management.

Edited August 2, 201114 yr by AMcCord

Jennifer,

We too have instituted the use of BCTA for our transfusions. If you are having problems with nursing basically thumbing their thumb at you, you can always enter an Occurance report thru MOX. What happens with the occurance report is that when you enter the report and input the managers names, they have to respond, plus all the occurance reports go to the quality risk department who have to follow up and fix the problem. A few times of nurses having to come back during their off time and finish their transfusions (unpaid at that) actually fixed my problem of their noncompliance, who wants to do the work but not be paid for it. If you continue to have problems, there is always your ethics and compliance department.

Thanks for the suggestions. We are now HFAP accredited, not Joint Commission. We just had our HFAP survey and got very lucky in the charts that were pulled for review. We are a smaller county hospital where a lot of the staff have been here longer than they can remember so any "new" ideas are not readily accepted or followed. We have been live with the electronic transfusion record for 7 weeks. My current audit shows about 40% of charting is complete...mostly missing vitals. This is not an improvement from paper charting, even though I was told repeatedly that the paper was the problem. I present my findings in 3 weeks at the Cross Functional team meeting (we do not have Transfusion Committee, long story!) My best resource for help and information is this web site, so appreciate the help!! I also audit transfusions live periodically. I know that if we have a recurrence of this at CAP inspection we are in deep doo. I'm trying to get Nursing and Administration to appreciate the seriousness of this. I'm just getting a little frustrated at this point!

We are a small New Jersey hospital with a big documentation problem. Nurses have been documenting electronically for about 18 months and the issues abound. When we were on paper, the problems were not much different, but I find it somewhat easier to audit the EMR (at least there are no issues with illegible entries and signatures).

So far, CAP and JACHO have not said anything but our State inspectors are very rigid about documentation and they went wild. Because I had thorough records of my audits I was told that the problem rests squarely with Nursing and that they had to develop a plan of action which we submitted with our response.

Since that time, I have worked with the managers, as well as the Education and Clinical Informatics departments by reporting my findings, with specific names of individuals who need extra help. Blood documentation was a focus of Nursing Competency this year, and there have been refresher classes as well as one on one where necessary.

One interesting point is that, there seemed to be a turning point for the better when I began to point out not only the nurses who were doing a poor job but also complementing those who consistently do a great and even an outstanding job of documentation. One manager said she was going to use those people as "blood buddies" to help those who were struggling.

We still have a long way to go and it is an uphill battle every day. Also it is very time consuming no matter what your strategy, but we seem to have little choice. In the end the responsibility always falls back to the blood bank.

Since your Administration is concerned, you must speak to them. As AMcCord and others have stated, make friends. I cannot believe that non-compliance has been tolerated.

See if the Administration can lure Nursing into Magnet Recognition! See who can commend and counsel, and the Nurse Managers should be empowered to train and document the training, then there are audits and re-training, its a Nursing process, all you have to do is to get them started. Documentation is important because if not available it can lead the hosptal to medico-legal problems. I dont know what more to say, but go to the top to get it done, change the CNO I am surprised really really surprised, and I applaud you for taking this matter into your hands.

The Joint Commission may move from the realm of being a "big stick" to that of a cudgel, mostly to the benefit of those of us in the field of transfusion medicine. TJC (which is what they want us to call it these days) has taken a deep and abiding interest in our domains and has been working for several years on new Blood Management Performance Measures. I'm essentially retired these days so I don't have my ear to the keyhole as I used to, so I don't know when they will publish these performance measures, but my recollections are that they are greatly interested in the subjects of blood conservation, the appropriateness of transfusion, and, of course, patient safety.

With the TJC's spotlight on the blood bank, our Blood Usage committees are likely to become more energized, and hospital administration may be beating a path to your door. Perhaps some of these performance measures will assist us in getting compliance with those who interface with the blood bank, over whom we seem to have little or no control, but at the very least there will have to be new lines of communication, and, hopefully, an era of greater cooperation.

We work so hard to ensure that the services we offer are of the highest quality, and that the blood products we process and issue are "safe, pure, and efficacious." Thus we would want our clinical partners at the bedside to be just as dutiful in their processes.

Absolutely Alan !!!!! Well said! I fully agree.

"We work so hard to ensure that the services we offer are of the highest quality, and that the blood products we process and issue are "safe, pure, and efficacious." Thus we would want our clinical partners at the bedside to be just as dutiful in their processes. "

Absolutely Alan !!!!! Well said! I fully agree.

"We work so hard to ensure that the services we offer are of the highest quality, and that the blood products we process and issue are "safe, pure, and efficacious." Thus we would want our clinical partners at the bedside to be just as dutiful in their processes. "

I second Liz and Alan on this. Transfusion safety is one of the two major focus points for TJC this year. We are expecting a visit from them any day now, so it will be very interesting to see how they judge our performance.

I would suggest looking at this doccumentation and ask a few questions such as:

How many times are the nurses required to document the same information? I know of facilities where the nurses are required to document vitals during transfusion as many as 3 different places each time. One should be enough for any one!

Is the documentation really required by anyone and/or does it really provide any value to the patient care or is it just another case of "we've always done it this way"?

Simplify and they will comply.

John makes a very good point. User friendly forms can definitely improve compliance. Our flow sheets, both the earlier paper versions and our EMR version were designed by a nursing committe with imput from me about what I needed from a regulatory viewpoint. If I get grumbles from nursing staff about the form, (if they actually have suggestions for improving the form rather than just gripes) I refer them to the committee. Most forms can benefit from tweaks suggested by the folks that use them.

I just went through the HFAP survey and THEY NOW REQUIRE A TRANSFUSION COMMITTEE LIKE JCAHO. So you don't have a choice in this matter. I had to start documenting our meetings in the lab since they discontinued the transfusion committee before I started last year. You will get cited. Show this to your lab manager and blood bank pathologist to start forming one. AABB has a wonder book on how Guidelines for Transfusion Committee that I just ordered.

Thanks for the suggestions. We are now HFAP accredited, not Joint Commission. We just had our HFAP survey and got very lucky in the charts that were pulled for review. We are a smaller county hospital where a lot of the staff have been here longer than they can remember so any "new" ideas are not readily accepted or followed. We have been live with the electronic transfusion record for 7 weeks. My current audit shows about 40% of charting is complete...mostly missing vitals. This is not an improvement from paper charting, even though I was told repeatedly that the paper was the problem. I present my findings in 3 weeks at the Cross Functional team meeting (we do not have Transfusion Committee, long story!) My best resource for help and information is this web site, so appreciate the help!! I also audit transfusions live periodically. I know that if we have a recurrence of this at CAP inspection we are in deep doo. I'm trying to get Nursing and Administration to appreciate the seriousness of this. I'm just getting a little frustrated at this point!

What is the number of this CAP question?