Does anyone use a provider signature form for transfusions with increased risks that are not for just uncrossmatched blood?  I would love any examples anyone might share of forms used to inform the provider (and get their signature) of things like incompatible units being issued (warm autos, DARA interference, no compatible units for antibody to high incidence antigen or a HTLA-like antibody, maybe even a compromised specimen that a provider insists must be used for testing or some such).  I'd appreciate any examples, explanations or procedures.

I have an incompatible form.  It states the nature of the incompatibility and documents the incompatibility and also that the Medical Director or designee has discussed the case with the attending.  It is based on my uncrossmatched form's format.  Don't have access to it right here and now but should be easy to make one up.  Run it by your risk management folks after your Medical Director approves.

This is included on our Emergency Release form.  We have a category for testing problems.  It includes unidentified antibody of unknown significance, probable cold agglutinin is present and may mask alloantibodies, a nonspecific autoantibody is present and may mask alloantibodies, the crossmatches are incompatible.  Finally there is the "other" with an explanation.

The physician signs the the statement "I understand the risk involved, but in my opinion, an emergency exists that requires the transfusion of potentially unsafe blood.  I release the facility from any and all liabilities attendant to the administration of this blood.  The medical director is consulted prior to release of blood in these circumstances.

Hope this helps.

Mabel, ours is a little different than our emergency release, in that the provider has to sign it prior to issuance of the blood.  We even had to create an order in patient keeper, which is our electronic provider ordering system, in case the provider was at home and too lazy to come in and sign it...

We also added the comment that the provider needed to discuss the additional risk with the patient.  I've attached a copy.

HIGH RISK TRANSFUSION FORM.doc

We have one form- Emergency/Medical Release form. Top portion is Emergency release with one of 2 parts we check- Emergency O uncrossmatched or Emergency type specific uncrossmatched. An emergency situation exists and transfusion prior to completion of testing is necessary due to life threatening conditions. I have been informed and understand the risks blah, blah blah.

The lower portion is the medical release with things we check, AB of undetermined, compatible units available, AB of undetermined- unable to find compatible, Rh positive product to Rh negative female of childbearing age, Blood Consent signature unattainable, Other. I am aware of problems encountered during compatibility testing. The medical status of this patient necessitates blah blah blah. I have been informed and understand the risks involved blah, blah, blah. Physician signs at the bottom.

Our policy states that we do not have to have the signature prior to either of these conditions. If it is an emergency, we will  get the signature when the crisis is over. If it is medical, we call the physician and tell them the issue and tell them they must sign the form. We will allow them to sign the next morning. If they don't sign I sic the HIM department after them when the patient is discharged. The physicians get in trouble here if they don't sign their orders. If it is something that is really out of the ordinary, I have my pathologist talk to the physician.

Our form is very similiar to the one DebbieL describes. We use ours in the same way - signature required, but not necessarily prior to transfusion. If the provider is being asked to sign for anything other than emergency release, one of our pathologists will contain them to discuss the patient's problem(s) and the risk.

We have one form for both Emergency Release and Incompatible transfusion.  We have a blank line that we fill in with the reason for release and then the tech, ordering physician, and pathologist must all sign and date the form.