SARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY
|
|
- Franklin Hines
- 5 years ago
- Views:
Transcription
1 SARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY TITLE: ADMINISTRATION OF BLOOD AND EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: 10/15/79 08/31/17 Clinical 1 of 7 Non-Clinical Job Title of Responsible Owner: Medical Director, Laboratory and Pathology Services PURPOSE: POLICY STATEMENT: EXCEPTIONS: DEFINITIONS: To establish guidelines for the administration of blood and blood components in areas authorized to do so. All registered nurses (RNs) who have successfully completed the Sarasota Memorial Health Care System (SMHCS) Orientation Program may administer blood and blood components. In addition, certified clinical perfusionists (CCP) and certified registered nurse anesthetists (CRNA) who have successfully completed the Perioperative Services orientation program may administer blood and blood components. Anesthesiologists (MDs/DOs) will have access to current SMHCS policies and procedures related to blood and blood administration, and are responsible for their own and their employees compliance. All licensed practical nurse IIs (LPN IIs) who have completed the blood and blood product class may administer blood and blood components via a peripheral and central line site. None None PROCEDURE: 1. SUPERVISION Transfusion must be prescribed and administered under medical direction. The patient must be observed during the transfusion and for an appropriate time thereafter for suspected adverse reactions. At SMHCS refer to Nursing Procedures (blo03, blo08, blo09) for time frames. If appropriate, subsidiaries will follow specific procedures. All transfusions shall be given in accordance with policies in the American Association of Blood Bank s Standards for Blood Banks and Transfusion Services and the policies and procedures of SMHCS. Specific instructions concerning possible adverse reactions must be provided
2 2 of 7 to the patient or a responsible caregiver when direct medical observation or monitoring of the patient will not be available after transfusion. (Refer to blo03 Reactions to Blood/Blood Components.) a. There shall be a system in place to ensure that physician s orders have been followed. b. At the patient s chart and prior to the administration of the blood or blood product, the RN, LPN II, CRNA, or CCP shall verify the product name with the physician s orders and charted crossmatch report. c. Personnel responsible for care of a patient receiving transfusion shall be appropriately trained in the recognition and treatment of adverse reactions. d. Personnel suspecting an adverse reaction to blood or a blood product shall discontinue the transfusion and maintain the intravenous line with normal saline. Personnel shall report any such suspected reactions to the patient s physician, obtain appropriate orders, and notify the Blood Bank immediately. 2. IDENTIFICATION There shall be positive identification of the recipient and the blood container. a. For crossmatched products, at the patient s chart and prior to administration of the blood or blood product, the RN, LPN II or CCP shall verify the product name with physician s order and the product unit number, product name and blood type with the charted crossmatch report (Refer to blo03 for specifics). b. Immediately before transfusion, and in the presence of the recipient, two approved staff (RN, LPN II, CCP, CRNA, MD/DO), one of whom is an RN, shall verify and document that all information identifying the container with the intended recipient has been matched, item by item. c. Immediately before transfusion, and in the presence of the recipient, two approved staff (RN, LPN II, CCP, CRNA, MD/DO) one of whom is an RN, shall verify and document that the unique ID number found on the blood armband the patient is wearing matches to the blood bag tag (SMH Policy 01.PAT.67, Blood Bank Identification Bands).
3 3 of 7 d. All identification attached to the container shall remain attached at least until the transfusion has been terminated. 3. GENERAL CONDITIONS OF TRANSFUSION Blood and components shall be maintained in a controlled environment at the designated temperature until released for transfusion. Blood and components must be transfused through a sterile, pyrogen-free transfusion set that has a filter designed to retain particles potentially harmful to the recipient. a. TRANSFUSION PROTOCOL - There shall be a written protocol for the administration of blood and blood components and the use of infusion devices and ancillary equipment. b. WARMING - Blood and blood components are generally not warmed prior to transfusion, but, when necessary, this should be accomplished during its passage through the transfusion set. (Refer to blo05-blood IV fluids warmer policy). The warming system must be equipped with a visible thermometer and, ideally, with an audible warning system. Blood must not be warmed above 37C. 1) Conditions that might require blood warming toward body temperature include massive, rapid transfusion; hypothermia; exchange transfusion of a newborn; or a patient with potent cold agglutinins. c. ADDITION OF DRUGS AND SOLUTIONS - Drugs or medications, including those intended for intravenous use, shall not be added to blood or components, nor administered via the same tubing through which blood components are infusing. 1) 0.9% sodium chloride, injection, USP, may be added to blood or components and shall be the flush solution when a flush solution is required for administration. 2) Other solutions intended for intravenous use may be used in an administration set or added to blood or components under either of the following conditions: a) They have been specifically approved for this use by the FDA.
4 4 of 7 b) There is documentation available to show that addition to the component involved is safe and efficacious. Normosol-R, ph 7.4 meets these requirements and is acceptable for use. NOTE: Lactated Ringers Injection USP, 5% Dextrose and Hypotonic Sodium Chloride solutions, as well as many other solutions and medications, shall NOT be used since they do NOT meet the requirements of Procedure #3.6.a. or b. above. 4. AUTOLOGOUS AND/OR DESIGNATED PRODUCTS There shall be policies and procedures in place to ensure that patients who have autologous or designated blood units set aside for them are given these units before allogeneic (regular Blood Bank inventory) units are given. a. Autologous units shall be selected and infused first. b. Designated units shall be selected and infused second. c. Allogeneic units shall be selected and infused last. 5. URGENT REQUIREMENT FOR BLOOD There shall be procedures for obtaining and administering blood and blood components in an emergency situation. a. In an emergency situation where delay in receiving blood components may jeopardize the patient s life, the physician must weigh the risk for transfusing uncrossmatched or incompletely crossmatched blood against the hazard of waiting for completed compatibility tests. In emergency situations, Group O red cells will be available from the Blood Bank on request. b. When uncrossmatched blood is released, a crossmatch shall be performed after receipt of a patient specimen in the Blood Bank. The physician shall be notified immediately of any incompatibilities. c. In an emergency, crossmatched blood will generally be available within minutes of receipt of a patient specimen in the Blood Bank. d. Established nursing procedures for the administration of blood and blood components shall be followed. 6. SPECIAL CONSIDERATIONS FOR ADMINISTRATION
5 5 of 7 OF BLOOD There is a marked increase in the danger of bacterial proliferation and red blood cell hemolysis of the blood unit if the transfusion extends longer than four hours per unit. The administration of blood components should begin within thirty (30) minutes after the product is removed from the Blood Bank. If it is not, it must be returned to the Blood Bank to be discarded. a. Blood components should be requested one at a time unless specifically ordered otherwise by the physician. b. Patient vital signs and patency of the intravenous access should be assessed prior to requesting the blood components. c. Blood and blood components must be infused per procedural guidelines and patient tolerance. d. Blood must be infused within four (4) hours. e. If for any reason it is suspected that the infusion of RBCs cannot be completed in the four (4) hour time limit, blood may be ordered in two (2) smaller units. Enter the request into the comment field of the blood requisition. The four (4) hour time limit will apply to the smaller unit sent. f. Specific situations may permit blood storage in a specifically designated, temperature-monitored Blood Bank refrigerator located in the Operating Room, Surgery Core, 4 EB, 5 EB, OR 22, 4 th floor Courtyard, 4 th floor OR. Red blood cells must not be allowed to cool below 1C or warm above 10C during transportation. 7. BLOOD OR BLOOD COMPONENT LOOKBACK Potentially HIV or HCV infectious blood and blood components are prior collections from a donor who tested negative at the time of donation but tests repeatedly reactive for the antibody to HIV or HCV on a later donation (window period of infectivity). a. Sarasota Memorial Health Care System has contracted with Suncoast Communities Blood Bank for transfusion services. Article 6.8 of that contract stipulates that Suncoast Communities Blood Bank will provide Look-back services for Sarasota
6 6 of 7 Memorial Health Care System as required by the Federal Department of Health and Human Resources and 42 CFR Section RESPONSIBILITY: REFERENCES: Directors of patient care areas will be responsible for ensuring that nursing personnel are aware and adhere to the provisions of this policy. American Association of Blood Banks, American Red Cross, the Americas Blood Centers. (Current Edition). Circular of information for the use of human blood and blood components. Arlington, VA: Author. Sarasota Memorial Heath Care System Policy. (2012) Blood Bank Identification Bands (01.PAT.67), SMH : Author Standards Committee for the American Association of Blood Banks, (Current Edition). Standards for Blood Banks and Transfusion Services. Bethesda, MD Author. U.S. Dept. of Health & Human Services. NH Publication Number (1990). Transfusion therapy guidelines for nurses. Washington, DC: Author. Suncoast Communities Blood Bank: Quality Assurance: Quarantine and Lookback, A0190, Rev. 09/14 AUTHOR(S): ATTACHMENT(S): Sue Key, MT (ASCP) SBB, Administrative Director of Laboratory Services of Suncoast Communities Blood Bank, Inc. Thomas J. Reed, MD, Medical Director, Laboratory and Pathology Services Jeffrey Zacks, M.D, Medical Director, North Port Laboratory Harold Vore, Administrative Director, Laboratory Services Maribeth Desiongco, Clinical Educator None
7 7 of 7 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy. Committees/Sections/Departments: N/A Date Director Laboratory Services, Suncoast Community Blood Bank Medical Director, North Port Laboratory Services Medical Director, SMH Laboratory Services Director/Responsible Owner: Chief of Nursing (if clinical policy or appropriate) Vice President/Executive Director: Chief of Medical Operations: (if clinical policy or appropriate) Chief of Staff: (if clinical policy or appropriate) Medical Executive Committee: (if clinical and review requested by CMO and COS) Sue Key Dr. Jeffrey Zacks, M.D Dr. Thomas Reed, M.D Harold Vore Connie Anderson Lorrie Liang Steve Taylor, M.D N/A N/A Chief Executive Officer: David Verinder, CEO
SARASOTA MEMORIAL HOSPITAL
SARASOTA MEMORIAL HOSPITAL TITLE: ISSUED FOR: NURSING PROCEDURE Nursing DATE: REVIEWED: PAGES: RESPONSIBILITY: RN, LPN I, LPN II Per Job Description 03/93 2/18 1 of 6 PURPOSE: KNOWLEDGE BASE: To provide
More informationSARASOTA MEMORIAL HOSPITAL
SARASOTA MEMORIAL HOSPITAL TITLE: NURSING PROCEDURE ORDERING, OBTAINING, IDENTIFICATION AND ADMINISTRATION OF BLOOD PRODUCTS (RBC, CRYOPRECIPITATE) BLOOD REACTIONS ADULTS AND PEDIATRICS DATE: REVIEWED:
More informationTitle: Massive Transfusion Event Protocol Policy: Clinical Manual/General Clinical
Title: Massive Transfusion Event Protocol Policy: Manual/General I. POLICY: Massive Transfusion Event (MTE) Protocol: The MTE Protocol is initiated at the request of the anesthesiologist, surgeon or physician
More informationDESCRIPTION/OVERVIEW This document standardizes the transfusion of packed red blood cells and/or other blood components.
Applies To: UNM Hospitals & UNMCC Responsible Department: Blood Bank Revised: 5/2017 Procedure Patient Age Group: ( ) N/A (X) All Ages ( ) Newborns ( ) Pediatric ( ) Adult DESCRIPTION/OVERVIEW This document
More informationSt. Vincent s East Page 1 of 5
St. Vincent s East Page 1 of 5 TITLE: PATIENT CARE PRACTICE GUIDELINE CARE OF PATIENTS BLOOD AND BLOOD COMPONENTS - ADMINISTRATION FACILITY: FUNCTION: ORIGINATING DEPT: St. Vincent s East HOSPITAL SHARED
More informationNOTE: Massive Transfusion Protocol (MTP) go to Appendix 17 and 17a for nursing guidelines and algorithm.
NURSING PROCEDURE TITLE: BLOOD PRODUCTS ADMINISTRATION Crossmatched & Uncrossmatched Products: Packed red blood cells, platelets, plasma, cryoprecipitate (homologous, autologous & directed donor) A. Prior
More informationREVISED: 7/03, 03/05, 04/08, 3/10, 11/11, 09/13, 3/14,1/15, 4/16
TITLE/DESCRIPTION: DEPARTMENT: PERSONNEL: BLOOD PRODUCT ADMINISTRATION CLINICAL LABORATORY ALL HOSPITAL EMPLOYEES EFFECTIVE DATE: 10/95 REVISED: 7/03, 03/05, 04/08, 3/10, 11/11, 09/13, 3/14,1/15, 4/16
More informationNOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section.
TITLE TRANSFUSION OF BLOOD COMPONENTS AND PRODUCTS SCOPE Provincial APPROVAL AUTHORITY Clinical Operations Executive Committee SPONSOR Provincial Transfusion Medicine Network Not applicable DOCUMENT #
More informationB LABELING AND COLLECTION OF SPECIMENS FOR BLOOD BANK
Effective Date: 12/17/2014 LABELING AND COLLECTION OF SPECIMENS FOR BLOOD BANK 1.0 Principle Proper identification of patient, patient s sample and blood products is crucial to safe transfusion. A correctly
More informationCLINICAL GUIDE TO TRANSFUSION
Leonor De Biasio, RN, BScN, CPNC, and Tihiro Rymer, BScN, MLT BACKGROUND This chapter focuses on the principles of safe blood transfusion practices. The aim of this chapter is to develop and support the
More informationSample. A guide to development of a hospital blood transfusion Policy at the hospital level. Effective from April Hospital Transfusion Committee
Sample A guide to development of a hospital blood transfusion Policy at the hospital level Name of Policy Blood Transfusion Policy Effective from April 2009 Approved by Hospital Transfusion Committee A
More informationSARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY
PS1006 SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY TITLE: NURSING AND PHARMACY GUIDELINES FOR THE ADMINISTRATION OF IV TREPROSTINIL (REMODULIN ) Job Title of Reviewer: Director, Pharmacy POLICY
More informationSARASOTA MEMORIAL HOSPITAL POLICY
SARASOTA MEMORIAL HOSPITAL POLICY TITLE PATIENT EXPIRATION, INCLUDING FETAL DEATH, PRONOUNCING OF PATIENT, AUTOPSY REQUESTS, POST- MORTEM CARE & MEDICAL EXAMINER CASES EFFECTIVE DATE: REVIEWED/REVISED
More informationSARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY
PS1006 SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY TITLE: NURSING AND PHARMACY GUIDELINES FOR THE ADMINISTRATION OF IV EPOPROSTENOL (FLOLAN, VELETRI ) POLICY #: EFFECTIVE DATE: REVISED DATE: POLICY
More informationSUNY Downstate Medical Center -University Hospital of Brooklyn Network Department of Pathology Policy and Procedure
SUNY Downstate Medical Center -University Hospital of Brooklyn Network Department of Pathology Policy and Procedure Subject: BLB 1 Procedures for Ordering Picking-up and Delivery of Blood Prepared By:
More informationReviewed 8/31/2013. Susan Parrish MSN RN
Reviewed 8/31/2013 Susan Parrish MSN RN After completion of this self study packet, the nurse should be able to: Identify the required components of the physician's order for blood transfusion products.
More informationINTERPROFESSIONAL PROTOCOL - MUHC
INTERPROFESSIONAL PROTOCOL - MUHC Medication included No Medication included THIS IS NOT A MEDICAL ORDER Title: This interprofessional protocol is attached to: Definition Administration of Labile Blood
More informationFY 15 BLOOD ADMINISTRATION/REACTION
1 FY 15 BLOOD ADMINISTRATION/REACTION Patient Care Services Policies PCS-205 Blood and Blood Components Transfusion: Initiation & Maintenance PCS-206 Blood and Blood Components: Transfusion Reaction PCS-207
More informationPatient Blood Management Certification Revisions
Issued October 3, 07 Patient Blood Management Certification Revisions Patient Blood Management (PBM) Certification Program Assessments: Internal and External (PBMAM) Chapter Standard PBMAM. The program
More informationBlood / Blood Products Transfusion A Liquid Transplant
Blood / Blood Products Transfusion A Liquid Transplant Caroline Holt Specialist Practitioner of Transfusion caroline.holt@tgh.nhs.uk Tel : 922 5484 Mob: 07759260044 The Transfusion Team Gillian Lewis Blood
More informationBlood Administration for Community Patients Policy
Blood Administration for Community Patients Policy Policy Title: Blood Administration for Community Patients Policy Policy Reference Number: PrimCare08/15 Implementation Date: Review Date: July 2010 Responsible
More informationBlood and Blood Products Administration
NCAL Patient Care Services 2016 Blood and Blood Products Administration Objectives: On completing this module, you will be able to: Identify blood group systems Describe compatibility requirements List
More informationADMINISTRATION OF BLOOD PRODUCTS (RED CELLS, PLATELETS, PLASMA, & CRYOPRECIPITATE) NICU SYRINGE METHOD
PURPOSE ADMINISTRATION OF BLOOD PRODUCTS To provide guidelines for the administration of blood products (red blood cells, platelets, plasma and cryoprecipitate) via syringe delivery in NICU SITE APPLICABILITY
More informationStandard Of Nursing Care During Blood Transfusion
Standard Of Nursing Care During Blood Transfusion Blood transfusion carries potentially serious hazards. Nurses Observations that should be carried out before, during and after a transfusion SHOT aims
More informationA Guide To Safe Blood Transfusion Practice
A Guide To Safe Blood Transfusion Practice Introduction To Blood Transfusion Safety Marie Browett, Pavlina Sharp, Fiona Waller, Hafiz Qureshi, Malcolm Chambers (on behalf of the UHL Blood Transfusion Team)
More informationEl Paso Integrated Physicians Group. Overview
El Paso Integrated Physicians Group Protocol Name Protocol Number Infusion Services 01 Effective Date 6/1/2015 Supersedes Protocol Dated N/A Overview This clinical protocol defines requirements and activities
More informationPOLICY FOR THE TRANSFUSION OF BLOOD AND BLOOD COMPONENTS
POLICY FOR THE TRANSFUSION OF BLOOD AND BLOOD COMPONENTS Document Author Written By: Transfusion Practitioner / Transfusion Laboratory Manager Authorised Authorised By: Chief Executive Date: July 2015
More information7 th Edition FACT-JACIE International Standards for Hematopoietic Cellular Therapy Product Collection, Processing, and Administration
7 th Edition FACT-JACIE International Standards for Hematopoietic Cellular Therapy Product Collection, Processing, and Administration Summary of Changes This document summarizes the major changes made
More informationManitoba Transfusion Best Practice Resource Manual Appendix 17 Guidelines for Perioperative Autologous Blood Collection and Administration
Guidelines for Perioperative Autologous Blood Collection and Administration Purpose These guidelines intend to inform health care providers about the principles of Perioperative Autologous Blood Collection
More informationSTANDARD OPERATING PROCEDURE FOR PATIENT HISTORY CHECK
STANDARD OPERATING PROCEDURE FOR PATIENT HISTORY CHECK 1.0 Principle 1.1 To review current patient results with previous records for possible discrepancies to check for special instructions or comments
More informationCOMBAT Research Study
COMBAT Research Study Questions & Answers What is the title of this research study? The Control Of Massive Bleeding After Trauma (COMBAT): A prospective, randomized comparison of early fresh frozen plasma
More informationIntra-operative Cell Salvage. Competency Assessment Workbook. Trainee: Hospital: Trainer/Supervisor: Date Commenced: Date Completed:
Intra-operative Cell Salvage Competency Assessment Workbook Trainee: Hospital: Trainer/Supervisor: Commenced: Completed: Contents Introduction 1-2 Record of Assessors 4 Confirmation of Required Pre-assessment
More informationSafe Blood Transfusion
Safe Blood Transfusion Cardiff & Vale uhb & Welsh Blood Service Education Sub-group Objectives Complex pathway Overview ~ pre-transfusion blood sampling ~ collection from blood bank fridge ~ administration
More informationSARASOTA MEMORIAL HOSPITAL POLICY
PS1070 POLICY TITLE: SARASOTA MEMORIAL HOSPITAL (SMH) PATIENT FLOW AND OVER EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: PAGE #: 12/1/05 05/12/17 Clinical Non-Clinical 1 of 11 Job Title of Responsible
More informationAdministration of blood components. Denise Watson Patient Blood Management Practitioner 11th January, 2016
Administration of blood components Denise Watson Patient Blood Management Practitioner 11th January, 2016 Introduction British Committee for Standards in Haematology guidelines Administration process Case
More informationSTANDARDIZED PROCEDURE ALLOGENEIC /AUTOLOGOUS HEMATOPOIETIC STEM CELL INFUSION (Adult, Peds)
STANDARDIZED PROCEDURE I. Definition: The infusion of allogeneic /autologous hematopoietic progenitor cells as a part of hematopoetic stem cell transplant or donor lymphocyte infusion. II. Background Information
More informationInfusion Therapy Learning Exercise: Infusion Documentation
Infusion Therapy Learning Exercise: Infusion Documentation INFUSION OF DOCUMENT IN DOCUMENT PERIPHERAL PICC LINE BLOOD TRANSFUSION SPINAL EPIDURAL CLPNA Infusion Therapy: Infusion Documentation Exercise
More informationPatient Self Administration of Intravenous (IV) Antibiotics at Home
Trust Policy Document Ref. No: PP(16)319 Patient Self Administration of Intravenous (IV) Antibiotics at Home For use in: For use by: For use for: Document owner: Status: Clinical Areas Clinical Staff Patient
More informationAccreditation Program: Long Term Care
ccreditation Program: Long Term are National Patient Safety Goals indicates scoring category ; indicates scoring category ; indicates situational decision rules apply; indicates 2009 The Joint ommission
More informationDepartment Policy. Code: D: MM Entity: Fairview Pharmacy Services. Department: Fairview Home Infusion. Manual: Policy and Procedure Manual
Department Policy Code: D: MM-5615 Entity: Fairview Pharmacy Services Department: Fairview Home Infusion Manual: Policy and Procedure Manual Category: Home Infusion Subject: Chemotherapy Purpose: Ensure
More informationPOSITION DESCRIPTION COLUMBUS REGIONAL HEALTHCARE SYSTEM CERTIFIED REGISTERED NURSE ANESTHETIST
POSITION DESCRIPTION COLUMBUS REGIONAL HEALTHCARE SYSTEM JOB TITLE CERTIFIED REGISTERED NURSE ANESTHETIST JOB CODE 0265 DEPARTMENT FLSA (Exempt/Non-Exempt) ANESTHESIA Non-Exempt DEPARTMENT DIRECTOR SIGNATURE
More information201 KAR 20:490. Licensed practical nurse intravenous therapy scope of practice.
201 KAR 20:490. Licensed practical nurse intravenous therapy scope of practice. RELATES TO: KRS 314.011(10)(a), (c) STATUTORY AUTHORITY: KRS 314.011(10)(c), 314.131(1), 314.011(10)(c) NECESSITY, FUNCTION,
More informationNEW ABO 2 Sample Protocol. Reducing the Risk to Mistransfusion
NEW ABO 2 Sample Protocol Reducing the Risk to Mistransfusion Thank You Dr.Charles Musuka MBChB, FRCPC, FRCPath Haematopathologist and Medical Director DSM Transfusion Medicine Brenda Herdman Technical
More informationSARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY
TITLE: SARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY REPORTING OF CRITICAL RESULTS AND DIAGNOSTIC PROCEDURES POLICY #: EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: 02/20/06 3/30/18 Clinical
More informationRight blood, right patient, right time. RCN guidance for improving transfusion practice. Past review date Use with caution
Right blood, right patient, right time RCN guidance for improving transfusion practice Acknowledgements We would like to thank everyone who reviewed this edition of Right blood, right patient, right time:
More informationHuman Milk. Neonatal Nursery Policy & Procedures Manual Policy Group: GI/GU Date Approved August 2012 Next Review August Approved by: Purpose
Approved by: Gail Cameron Director, Maternal, Neonatal & Child Health Programs Human Milk Neonatal Nursery Policy & Procedures Manual : August 2012 Next Review August 2015 Dr. Ensenat Medical Director,
More informationATLANTICARE HEALTH SYSTEM AtlantiCare Regional Medical Center ID #: 3581 DEPARTMENT: GENERAL CATEGORY: PROVISION OF CARE
POLICY: Blood products must be administered in accordance with the procedures defined below. PURPOSE: To provide guidelines or the issue, initiation and termination of transfusion of blood products as
More informationTransfusion of Blood Components and Products
Approved by: Vice President & Chief Medical Officer; and Vice President & Chief Operating Officer Transfusion of Blood Components and Products Corporate Policy & Procedures Manual Number: VII-B-395 Date
More informationCONSENT FOR SURGERY OR SPECIAL PROCEDURES
Admission Date THE VALLEY HOSPITAL CONSENT FOR SURGERY OR SPECIAL PROCEDURES - Colonoscopy 1. Authorization. I hereby authorize Dr. (" my Doctor") and any such assistants or designees as may be selected
More informationThe Joint Commission Medication Management Update for 2010
Learning Objectives The Joint Commission Medication Management Update for 2010 U.S. Army Medical Command Fort Sam Houston, TX Describe most recent changes in The Joint Commission (TJC) Accreditation Program
More informationPRE-INSPECTION QUESTIONNAIRE INSTRUCTIONS
PRE-INSPECTION QUESTIONNAIRE INSTRUCTIONS! Submit copies of all documents or records outlined below. If you do not have the required information, indicate whether or not you expect to have it at the time
More informationQuality Medical and Laboratory Practice in Cellular Therapy
Quality Plans: Development and Implementation ISCT Annual Meeting May 24, 2010 Lizette Caballero, B.S., M.T.(ASCP) Laboratory Manager Florida Hospital Cellular Therapy Laboratory Quality Plan: Development
More informationSARASOTA MEMORIAL HOSPITAL POLICY
PS1013 TITLE: SARASOTA MEMORIAL HOSPITAL POLICY EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: 11/18/05 04/20/18 Clinical Non-Clinical 1 of 6 Job Title of Responsible Owner: Director, Cardiac and
More informationIf viewing a printed copy of this policy, please note it could be expired. Got to to view current policies.
If viewing a printed copy of this policy, please note it could be expired. Got to www.fairview.org/fhipolicies to view current policies. Department Policy Entity: Fairview Pharmacy Services Department:
More informationFitting Automation into a Small Transfusion Service
Fitting Automation into a Small Transfusion Service Jo Bruner, MLS (ASCP) CM Blood Bank, Hematology & Coagulation Section Head Fulton County Health Center Laboratory Objectives - List the advantages and
More informationRisk Assessment Form HS 9 (1)
s Full Name: Date of Birth: NHS Number 1. The fully implanted port system Sitimplant is not regularly used in the community and nursing staff may be unfamiliar with the recommended care of this system
More informationTo provide information about the role of the pharmacy in Infection Prevention and Control.
TITLE/DESCRIPTION: Pharmacy DEPARTMENT: Pharmacy PERSONNEL: Pharmacy Personnel EFFECTIVE DATE: 1/97 REVISED: 4/97, 7/08, 12/11, 1/15 I. PURPOSE To provide information about the role of the pharmacy in
More informationDocument Details. notification of entry onto webpage
Document Details Title Patient Group Direction (PGD) Administration of sodium chloride 0.9% injection by registered professionals Trust Ref No 1987-38096 Local Ref (optional) Main points the document As
More informationSARASOTA MEMORIAL HOSPITAL PERIOPERATIVE DEPARTMENT POLICY
SARASOTA MEMORIAL HOSPITAL PERIOPERATIVE DEPARTMENT POLICY TITLE: ANESTHESIA CARE AND INTRAOPERATIVE Job Title of Responsible Owner: EFFECTIVE DATE: REVIEW/REVISED DATE: TYPE: Director of Perioperative
More informationRecommendations from National Patient Safety Agency alerts that remain relevant to the Never Events list 2018
Recommendations from National Patient Safety Agency alerts that remain relevant to the Never Events list 2018 January 2018 We support providers to give patients safe, high quality, compassionate care within
More informationBlood Products Policy
Blood Products Policy Originator: Corinne Revens, Ward Sister Jane Creed, Senior Registered Nurse Miranda Green, Registered Nurse Review date: August 2013 Revision date: August 2015 Approved by: Clinical
More informationCELLULAR THERAPY PRODUCT COLLECTION, PROCESSING, AND ADMINISTRATION DOCUMENT SUBMISSION REQUIREMENTS
CELLULAR THERAPY PRODUCT COLLECTION, PROCESSING, AND ADMINISTRATION DOCUMENT SUBMISSION REQUIREMENTS FACT-JACIE International Standards for Cellular Therapy Product Collection, Processing and Administration,
More informationProcedure. Applies To: UNM Hospitals Responsible Department: HIM / Admitting/ Blood Bank Revised: 8/2015
Title: Patient Re-identification, Information Correction, and Duplicate Medical Record Number Removal Applies To: UNM Hospitals Responsible Department: HIM / Admitting/ Blood Bank Revised: 8/2015 Procedure
More informationCLINICAL CHEMISTRY. Phone: The department is staffed 24 hours a day.
CLINICAL CHEMISTRY Phone: 922-4488 Hours: The department is staffed 24 hours a day. Monday Friday Saturday Sunday Days: 8:00 a.m. - 4:30 p.m. Full Testing Limited Limited Evenings: 4:00 p.m. - 12:30 a.m.
More informationDISTRICT NURSING and INTERMEDIATE CARE
CLINICAL GUIDELINES DISTRICT NURSING and INTERMEDIATE CARE Schedule of guidelines attached: DNICT03 Community Procedure for the Administration of Intravenous Drugs via Bolus The guidelines scheduled above
More informationHealth Service Circular
Health Service Circular Series number: HSC 1998/224 Issue date: 11 December 1998 Review date: 11 December 2001 Category: Clinical Effectiveness Status: Action sets out a specific action on the part of
More informationSPECIMEN REQUIREMENTS
SPECIMEN REQUIREMENTS General Guidelines for Specimen Handling Specimen requirements generally include the requested volume, storage temperature, and any special handling notes. The requested volume provides
More informationAdministration of IV Medication in the Community by the Children s Community Nursing Team Standard Operating Procedure
Administration of IV Medication in the Community by the Children s Community Nursing Team Standard Operating Procedure DOCUMENT CONTROL: Version: 1 Ratified by: Clinical Quality and Standards Group Date
More informationHome+ Home+ Home Infusion. Home Infusion. regionalhealth.org/home
Department of Regional Health Rapid City Hospital 224 Elk Street, Suite #100 Rapid City, SD 57701 605-755-1150 Toll Free 844-280-9638 Fax 605-755-1151 regionalhealth.org/home 20160810_0917 Regional Health
More informationInfection Prevention and Control and Isolation Authored by: Infection Prevention and Control Department
Infection Prevention and Control and Isolation 2015 Authored by: Infection Prevention and Control Department Objectives After you complete this Computer-Based Learning (CBL) module, you should be able
More informationQuality Management of Apheresis Personnel
In: McLeod BC, Price TH, Weinstein R, eds. Apheresis: Principles and Practice, 2nd Edition Bethesda, MD: AABB Press, 2003 Quality Management of Apheresis Personnel 32 Quality Management of Apheresis Personnel
More informationTrust Policy for Blood Transfusion
Trust Policy for Blood Transfusion Approval and Authorisation Reviewed by Job Title Date Simon Middleton Chair of Hospital Transfusion Committee 03.09.2010 Rebecca Sampson Consultant Haematologist 01.09.2010
More informationLimitations and Guidelines Revised for Elastomeric Devices and IV Supplies and Equipment
Limitations and Guidelines Revised for Elastomeric Devices and IV Supplies and Equipment Information posted January 8, 2007 Effective for dates of service on or after March 1, 2007, benefit limitations
More informationImproving the Safe Use of Multiple IV Infusions
QUICK GUIDE Improving the Safe Use of Multiple IV Infusions The AAMI Foundation is grateful to its collaborating partners in the National Coalition for Infusion Therapy Safety: Acknowledgements The AAMI
More informationAPHERESIS UNIT ORIENTATION
INTRODUCTION What is Apheresis? Apheresis is a procedure by which fluid or cellular components are separated from the circulating blood either for the preparation of transfusion products (donor apheresis)
More informationStandards, Guidelines, and Regulations
Standards, Guidelines, and Regulations Theresa C. Stec BA, MT(ASCP) Biovigilance Program Manager Surgical System Administrator Perioperative Services Baystate Medical Center Springfield, MA Standards,
More informationSFHPCS19 - SQA Code HD1K 04 Prepare equipment for intra-operative blood salvage collection
Prepare equipment for intra-operative blood salvage collection Overview This National Occupational Standard is about preparing equipment necessary to collect blood salvaged intra-operatively. Users of
More informationDonor Human Milk (DHM)
Approved by: Gail Cameron Senior Director Operations, Women s & Child Health Dr. Sharif Shaik Medical Director, Neonatology Donor Human Milk (DHM) Neonatal Policy & Procedures Manual : December 2015 Date
More informationWhat is the Massive Transfusion Protocol (MTP)? Provision and mobilisation of large
RCH Massive Transfusion Protocol medical Dr. Helen Savoia Nicole vander Linden Mary Comande What is the Massive Transfusion Protocol (MTP)? Provision and mobilisation of large amounts of blood product
More informationBaptist Health South Florida. Transfusion Services: Standardizing the Type & Screen Process Introducing Bar Code Blood Bands
Baptist Health South Florida Transfusion Services: Standardizing the Type & Screen Process Introducing Bar Code Blood Bands June 2011 O II. bjectives I. Review process for the Collection of Type & Screen
More informationStaff Responsible Procedure Rationale/Reason
Subject: Patient Controlled Analgesia Date: October 2011 UPMC St. Margaret UPMC St. Margaret Harmar Outpatient Center Clinical Practice Council Policy #2005 Overview: To promote appropriate PCA use and
More informationCommunity Health Network, Inc. MEDICAL STAFF POLICIES & PROCEDURES
Community East Community South Community North TITLE: Medical Record Chart Requirements The medical record of care comprises all the data and information about a patient s visit. It functions as both a
More informationINFECTION CONTROL SURVEYOR WORKSHEET
Attachment 2 Exhibit 351 INFECTION CONTROL SURVEYOR WORKSHEET Instructions: The following is a list of items that must be assessed during the on-site survey, in order to determine compliance with the infection
More informationStandard Operating Procedure for Patients Referred for Blood Transfusion to Louth Clinical Decision Unit by General Practitioners.
Standard Operating Procedure for Patients Referred for Blood Transfusion to Louth Clinical Decision Unit by General Practitioners. Reference number: G_CS_87 Version: 1 Ratified by: LCHS Trust Board Date
More informationRoyal Wolverhampton Hospitals NHS Trust. Job Description Haematology
Royal Wolverhampton Hospitals NHS Trust Job Description Haematology Job Title: Grade: A4C Band 3 (Point 7) Directorate: Pathology Department: Haematology Reports to: BMS staff and section senior Professionally
More informationSARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE
SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE TITLE: ISSUED FOR: HEMODIALYSIS TEMPORARY CATHETER (INSERTION, DRESSING CHANGE, REMOVAL, MEDICATION AND BLOOD DRAWS, DISCONTINUATION OF MEDS AND IV FLUIDS)
More informationWYOMING STATE BOARD OF NURSING ADVISORY OPINION INTRAVENOUS THERAPY BY LICENSED PRACTICAL NURSES
WYOMING STATE BOARD OF NURSING ADVISORY OPINION INTRAVENOUS THERAPY BY LICENSED PRACTICAL NURSES Advisory Opinion Number: 03-123 Board Meeting Date: April 28-May 1, 2003 January 7-10, 2008 February 18,
More informationSARASOTA MEMORIAL HOSPITAL PERIOPERATIVE DEPARTMENT POLICY
PS1070 SARASOTA MEMORIAL HOSPITAL PERIOPERATIVE DEPARTMENT POLICY TITLE: ADMISSION/DISCHARGE CRITERIA: POST ANESTHESIA CARE UNITS (PACU) EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: Job Title of
More informationNational Marrow Donor Program /Be the Match 23rd Edition Standards And Glossary January 1, 2016 Notice and Disclaimer NMDP/Be the Match Standards
National Marrow Donor Program /Be the Match 23rd Edition Standards And Glossary January 1, 2016 Notice and Disclaimer NMDP/Be the Match Standards These standards apply to activities performed by National
More informationBlood Transfusion Policy. Version Number: 6.1 Controlled Document Sponsor: Controlled Document Lead: On: December 2014.
Blood Transfusion Policy CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Policy Clinical The policy describes the framework and principles required to deliver best transfusion
More informationA Team Approach To Decrease Wasted Blood Products
QUALITY IMPROVEMENT Leigh Jefferies, MD M. Elizabeth Smith, MT(ASCP)SBB Deborah Magee, MT(ASCP)SBB Patricia Wallace, MSN, RN, CCRN Meg Horgan, MSN, RN A Team Approach To Decrease Wasted Blood Products
More information1. Introduction. 1 CMS section
1. Introduction Anesthesiology is the practice of medicine including, but not limited to, preoperative patient evaluation, anesthetic planning, intraoperative and postoperative care and the management
More informationClinical Interdepartmental Policy and Procedure
Clinical Interdepartmental Policy and Procedure Policy: Staff Response to Medical Errors/Adverse Events Policy Number: MR-006 Joseph S. Gordy, CEO Signature: Flagler Hospital Originator: President Coordinating
More informationDirectly Observed Therapy for Active TB Disease and Latent TB Infection
Directly Observed Therapy for Active TB Disease and Latent TB Infection Policy Number TB-5001 Effective Date (original issue) September 6, 1995 Revision Date (most recent) June 26, 2008 Subject Matter
More informationBlood Bank Rotations Goals and Objectives. Rotation Director: Robertson Davenport, M.D.
Blood Bank Rotations Goals and Objectives Rotation Director: Robertson Davenport, M.D. The goal of the First Blood Bank Rotation is for the resident to move from being a Novice (A novice knows little about
More informationACCOUNT NO. MED. REC. NO. NAME BIRTHDATE. Patient Identification ALL ORDERS MUST BE MARKED IN INK WITH A CHECKMARK ( ) TO BE ACTIVE.
PO7071 *PO7071* Page 1 of 4 ALL MUST BE MARKED IN INK WITH A CHECKMARK ( ) TO BE ACTIVE. Weight: kg Height: cm Allergies: Treatment Start Date: Date(s) of Transfusion(s): Current Labs: WBC: Hgb/Hct: Platelets:
More informationPRE-INSPECTION QUESTIONNAIRE INSTRUCTIONS
PRE-INSPECTION QUESTIONNAIRE INSTRUCTIONS Submit copies of all documents or records outlined below. If you do not have the required information, indicate whether or not you expect to have it at the time
More informationBLOOD TRANSFUSION POLICY
Title: BLOOD TRANSFUSION POLICY Ref: 0219 Version 11 Classification: Guideline Directorate: Laboratory Medicine Due for Review: 15/12/2020 Document Control Responsible Consultant Haematologist and Transfusion
More informationCENTRAL IOWA HEALTHCARE Marshalltown, Iowa
CENTRAL IOWA HEALTHCARE Marshalltown, Iowa CARE OF PATIENT POLICY & PROCEDURES Policy Number: 4.37 Subject: Implanted Venous Access Device (Infus-A-Port), Nursing Management Of (Indwelling Vascular Access
More informationMARSHALLTOWN MEDICAL & SURGICAL CENTER Marshalltown, Iowa
MARSHALLTOWN MEDICAL & SURGICAL CENTER Marshalltown, Iowa CARE OF PATIENT POLICY & PROCEDURES Policy Number: 4.37 Subject: Implanted Venous Access Device (Infus-A-Port), Nursing Management Of (Indwelling
More information