STANDARD OPERATING PROCEDURE FOR PATIENT HISTORY CHECK

Transcription

1 STANDARD OPERATING PROCEDURE FOR PATIENT HISTORY CHECK

2 1.0 Principle 1.1 To review current patient results with previous records for possible discrepancies to check for special instructions or comments that have been previously documented. This will assist in the selection of appropriate blood products for transfusion/infusion. 2.0 Scope and Related Policies 2.1 A patient history check shall be preformed on specimens received in the transfusion medicine laboratory. This history check shall be documented. 2.2 Previous results must be compared with current results and discrepancies resolved. 2.3 Previous admission records and/or previous patient history data alone shall not be used to determine the patients ABO and Rh type. 2.4 There shall be an established hospital policy regarding patient history check when Laboratory Information System (LIS) is unavailable. 3.0 Specimens-N/A 4.0 Materials Laboratory Information System (LIS) Requisition or electronic order entry 5.0 Quality Control N/A Page 2 of 6

3 6.0 Process Flowchart 6.1 Process Flowchart Check for previous patient record Was previous record found? NO Document patient information in LIS or on patient requisition YES Verify patient information Was discrepancy identified? YES Resolve discrepancy NO Complete required tests Compare current and previous records Is there a discrepancy? YES Resolve discrepancy NO Document comparison was performed Page 3 of 6

4 7.0 Procedure 7.1 Check for previous patient record by using MCP number or unique identification number. 7.2 If a previous record is found: Compare and verify patient information. (Name, date of birth and identification number) between the requisition and information on file. Any discrepancies must be resolved Complete current test and compare results with previous records for the following records: Previous ABO and Rh groupings Complications in determining blood type Clinically significant red cell antibodies Adverse reactions to a previous transfusion/infusion Special requirements, if applicable (e.g. CMV negative or irradiated) This comparison must be documented. 7.3 If no previous history is found for the patient, all pertinent information regarding patient transfusion history must be documented on at least one of the following: LIS (i.e. Meditech, Medical Records, or other information system) Patient s requisition 8.0 Reporting N/A Page 4 of 6

5 9.0 Procedural Notes 9.1 If a clinically significant red cell antibody(s) is detected in the patient sample or there is a history of an antibody in the patients file, select antigen negative red cell components for transfusion There must be a specific facility procedure for a computerized history check Records Management 10.1 The following information should be kept indefinitely: Recipient transfusion data file in the Transfusion Medicine Laboratory All serologic test records Serious adverse reaction All information required for look back or trace back purposes 10.2 All transfusion records in the recipient s medical chart shall be retained in accordance with health care facility policy Request form for serologic tests shall be retained for one month Documentation of staff training and competency must be kept for a minimum of ten years.this shall include the signature of the person, identification and initials. Page 5 of 6

6 References Canadian Standards Association. (2010). Blood and blood components Z Mississauga, ON: Author. Canadian Standards for Transfusion Medicine. (2011). Standards for hospital transfusion Services. (Version 3.0). Ottawa, ON: Author. Manitoba Provincial Blood Coordinating Office. (2007). Manitoba transfusion quality manual for blood banks. (Version 2.0). Winnipeg, MB: Author. Roback, J., Grossman, B., Harris, T. & Hillyer, C. (2011). Technical manual. (17 th ed.). Bethesda, Maryland: AABB. Transfusion Ontario Programs Ottawa Office. (2009). Ontario regional blood coordinating network standard work instruction manual. Ottawa, ON: Author. Page 6 of 6