My hospital system is trying to standardize the process of auditing across several very different hospitals. Our current practices range from sending a form up for nursing to complete on each patient (not each unit) in the bigger hospitals, to following one unit to the floor each month in a smaller hospital, to following a unit whenever they can in the small hospital that only does about one transfusion a month. I would love to hear how others are handling this. How do you document? How many audits is "enough"? What can you do about it if you note deficiencies on the nursing side? Is a blood banker really qualified to document the transfusion process on the floor?

Thanks in advance for any thoughts you can share.

Sandi

We send a Lab Scientist (Tech) or lab asst up with a checklist to observe the first 15 min of a transfusion. We do at least 5 per quarter at our bigger hospital--try for 10 to get better statistics. We need to roll this out at the smaller hospitals in our system but haven't yet.

I used to audit 1 transfusion/month - acutally go and watch the process. Nursing has been 100% for the past few years so I've dropped that audit. We do audit 100% of transfusion forms for completeness - improvements from <50% then to 95%+ now.

I used to audit 1 transfusion/month - acutally go and watch the process. Nursing has been 100% for the past few years so I've dropped that audit. We do audit 100% of transfusion forms for completeness - improvements from <50% then to 95%+ now.

What did you do to cause improvement from 50% to 95%? We battle with that constantly, but never seem to make any real progress.

We brutalized Nursing administration with data; it did not hurt us that CAP cited the inconsistencies in completing the transfusion documents and a f/u by Quorum (I think) further supported our cause. It was an uphill battle. There are still small glitches in their reporting but the improvements have been dramatic.

David, What information is included on your transfusion form? Computer generated? I am looking at the forme we have and am thinking that they do not include as much information as I would like.

We document: pretransfusion info to pt/pre-vitals/time started - 2 RNs check donor/pt info; vs at 15 min and hourly after that/end time - observation for trans rx. This is online documentation, there is no paper form except during downtime.

I'm jealous...I want computer documentation...But I will settle for a BB computer system with nice forms.

We perform a monitor each month by observing the process from the time that the blood is issued until it is started. This is followed by a few questions and the rest of the information is obtained from the transfusion form. I rotate it between nursing units. A copy of the form is sent to the nurse manager along with my findings. I also review all of the transfusion forms that are returned to the lab. We have 2 classifications of variances (QA doesn't like the word errors) - trnasfusion related and incomplete documnetation. When I started the compliance rate was about 65% and now it is about 90%. Each one is returned to the nurse manager.

It may be a pain but I am seeing results.

I'm jealous...I want computer documentation...But I will settle for a BB computer system with nice forms.

Yeah - I'd like a BBIS too . . .

For those of you who are reviewing 100% of your completed transfusion forms, I have a question.  Are your forms 2-ply and the second copy returned to the transfusion service for review?  If not, how do you obtain a copy for review?  Currently our transfusion forms are preprinted and the patient information is printed on a Lexmark 2500 serires form printer (continuous feed).  The second copy of the form is returned to us after completion of the transfusion. 

Thanks!

When we were on paper, the transfusion flowsheet was a 2 part form. We were supposed to get the back 'carbon' copy after completion of the infusion. We usually got the form by end of shift, sometimes the next day and sometimes a week or 2 later when the medical records people found the entire form on the chart (some folks just can't follow instructions). Our flowsheet is now in the EMR. I can access those online. It is limited access - lab supervisors and specifically designated staff.

We have about a 61% completeness compliance right now, with the majority of blanks for volume transfused, although enough have vital info missing that it's being strongly addressed with nursing now.  Our forms are scanned into Meditech, but not until after the patient is discharged.  We will be implementing TAR soon, so I hope our audits can be more "real time."