I am really needing assistance from experienced blood bankers. I recently was assigned to perform a minimum of 10 transfusion audits per month. I made a comprehensive checklist from our BB and Nursing procedures and have started observing transfusions from issue in the lab to transfusion on the nursing floor. I have noticed several discrepancies from our written procedure:

1. 15 minute vitals taken 15 minutes after first set - yet the patient hasn't actually received any red cells yet - the first set was taken when the nurse arrived in the room, then there was a delay in getting everyone and everything started so the patient received saline only....

2. Nurse started unit then promptly left. Her instructions to the patient were to use the call light if the patient felt funny. After about 20 minutes the Nurse tech entered room and wrote something on the door in the patient's room. Nurse eventually returned after 25 minutes and wrote on the transfusion card. When questioned she said she was writing the vitals taken at 15 minutes by the nurse tech. She said the Dynamap took the vitals - when I know that actually no one took any vitals since I was observing in the room the whole time. Our policy says that the transfusionist is to remain "close" during the first 15 minutes. During those 25 minutes the nurse was chatting on her phone and visiting with other nurses and did not return to the room at all during this time.

My dilemma - and I really need help with this - I reported my findings to transfusion committee and was told that I needed to report these issues to the nurse manager. I did so and the nurse manager complained to the DON. I've been told by the DON that nurses do not need to stay in the room with the patient during the first 15 minutes and that it is just not feasible. I also conducted an audit in the ED and the nurse was somewhat inexperienced at starting transfusions. The nurses asked each other what rate to start with and decided on 150. Our policy states that units should be initiated at a rate of 60 for 15 minutes. I told the nurse (politely) that I believed that the policy said 60-80. The nurse asked the charge nurse and the charge nurse said 120. The charge nurse then looked up the policy and discovered that it said 60 and said that he'd never initiated a transfusion at less than 100 in all the years he'd worked at the institution. He did not seem to be angry or upset, but later he complained to the DON.

I received an email from the DON saying that nurses do not need to stay in the room with the patient during the first 15 minutes and that it is just not feasible. She also said that she received a call from the ER and they were VERY upset that I was conducting audits in the ER without any notice. I sent an email to the COO and risk manager and Quality Director about my concerns - that the DON is reporting that nursing does not need to stay in the room to observe the patient for 15 minutes and that the ER staff had seemed to welcome the information I was sharing with them. The COO is backing up the DON and as long as patients have call lights and nurses are close by we are following the policy and yet is the one mandating that I the perform the audits. What is the point of doing an audit if I am not permitted to report my findings and am getting the staff all upset?

I have been a Blood Bank Supervisor for 20+ years and currently the Lab Manager for 4 years. So, why you ask are we doing these audits now? A Nurse with one of our contracted services gave an A pos unit of blood to an O Pos patient. Our blood bank has passed FDA and CAP investigation - yet we are being held accountable for the error by nursing staff. The audits are being done as part of an action plan for CMS.

So, I am asking for your help on what your institution's policy is during that 15 minutes and how you define "close". I want to make sure that I continue to push for patient safety and YES I've started a job search.:cries:

Wow! I'm sorry I don't have any advice, but I wanted to say that is awful! Seems DONs can get away with a lot. We had one that stated that her nurses were too busy to take critical value results over the phone!

I review all of our transfusion forms(approx. 225-250/month) and send a QA form to the nurse manager if nursing protocols were not followed. This includes vital times and proper completion of the form. It is up to the manager to review these with the staff involved. Our compliance rate is below 15% and sometimes below 10%. I also perform a transfusion monitor following a transfusion from pickup in the BB to thriygh the start of the transfusion and then ask questions regarding the rest of the procedure.

Report the replies of the DONs to the transfusion committee . . . You are going to have a sentinel event if nursing cannot stay for the 1st 15 minutes. If you are AABB or CAP or JCAHO accreditted maybe you can get them to "ding" your transfusions. You may also want to contact your state health dep't and ask their advice. NOT staying wth the patient is dangerous (and scary too)! I have found that Nursing compliance with transfusion protocols is not very good (as KKidd intimates).

By the way, before I started reviewing each transfusion form, our compliance was 30% in some units. It takes some work to get compliance and you need a strong CNO and NEC. One of the nurse managers prepared an in-service that took them step by step as they performed a transfusion. I participate in nursing orientation and skills fairs.

This sounds like something that could/should be taken to risk management as well. That may get a response when nothing else will.

OK, I have a couple of suggestions when dealing with nursing staff. You need to approach this from a political stand point first. Question here, have you engaged the DON in a conversation with documentation why you feel it’s important that a nurse be with the patient for 15 minutes, maybe they just don’t know the stats? Sometime we forget that not even doctors spend time dealing with transfusion medicine in their schooling. If that does not work.

You don’t need nursing services on board for you to get what you want. Don’t get me wrong it’s nice to have nurses with buy in, but not mandatory. Your medical director needs to present the stats at the meeting he has each week/month with all the other doctors. Let him drive it from the top down. Doctors can have a more profound effect on nurses then the lab every can. I really think this is where your transfusion committee should be getting involved, not sure who’s on yours or what the purpose of it is, but addressing policy is usually a function of the committee.

You audits should be presented at the transfusion committees. The committee told you to report them to the nursing, which I would do only to the DON from now on, place all that liability in the DON lap. Make sure the DON knows that you are placing that “responsibility and liability” on them. Words like that get people’s attention. You must follow up with the transfusion committee and report the feedback you received from nursing. It may also be time to get you executive level (your equivalent to the DON) boss engaged in the conversation with the DON. A sentinel event will potential get the laboratory blood bank closed down even if it’s the nurses not doing their job. As David said it going to happen, just a matter of time. Make sure that your bosses know that this is not on the laboratory if this happens. Make sure you have good solid documentation. It appears it’s time for the lab to start documentation to protect itself from an inevitable law suit.

At the very least you need to get them to define in writing what close means. If you are considered about this close, during your audit hit the call button and see how long it takes the nurse to respond to it. It’s your call, but I think I would notify the DON before I tried this.

If you present information on why a nurse should stay, make sure to include Anaphylactic Transfusion Reactions, due to the increased risk of patient incapacitation in a very short amount of time (I.E. can’t hit the call button).

The current policies for the Armed Services Blood Program mandate that a nurse remains with the patient for the first 15 minutes of the transfusion. There are over 300 Armed forces hospital’s following this protocol. Can only provide this link: http://www.militaryblood.dod.mil/

Please take what I am about to say in the spirit it is given which is one of trying to help.

First the act of transfusing a patient is a nurse function not a blood bank/transfusion service function unless you are one of those rare facilities that have a transfuison team under the the blood bank/transfusion service. The rules and regulations covering this activity are controlled by either local, state or federal nursing governing bodies not CAP or AABB, that's why you won't find them in the Standards. As such you are obviously not in a postion to enforce this.

I never have understood why we were always cast in the role of transfusion police but obviously we have been.

Second, nurses will protect nurses and administration will protect nurses so my experience with this type of situation has lead me to realize that your best ally will be a good, agressive Risk Manager. Nothing like the threat of a significant law suit to get administration's attention. You best support will be researching the regulations that control transfusions in your area and see how closely your facility's SOPs match these regulations.

Third, document everything you do as thoroughly and completely as possible to include all of you interactions with everyone up the food chain. This is fondly know as CYA for a very good reason.

Finally, know when to step back from it. The may come a point when all avenues as well as your desire to continue is exhausted. At that point you'll just have to let them hang themselves and hope the patient involved survies.

Good luck.

I have been where you are at a previous institution--John's advice is spot on! Nursing personnel would not listen and did exactly what your nurses did which prompted a NYS inspector to come in to look at the process. The investigation started in the direction of this being a transfusion service (lab) issue until I showed the minutes reporting the issues at a Transfusion Committee meeting and nursing division stating that they were not going to change. The investigator then turned the investigation to nursing; once written directly that nursing processes were not compliant, changes were made. This entire process occurred over 2 1/2 years.

Good Luck!! It could be a long process to clean up.