sion Medicine Quality Manual - PDF document

Transfu sion Medicine Quality Manual Guidelines for Pat ient Identification and Labeling of Pre - Transfusion Specimens Provincial Blood Coordinating Program _______________________________________________________________________ This document may be incorporated into each Regional Policy/ Procedure Manual. NL2010 . - 014 Version: 3.0 Effective Date: 20 15 - 05 - 14 Page 2 of 7 Guidelines for Patient Identific ation and Labeling of Pre - transfusion Specimens 1.0 Policy Statements 1.1 There shall be positive, unequivocal ident ification of a patient from sample collection through to transfusion . 1.1.1 Patient identifiers shall be used to confirm positive patient identification using the patients identification band, healthcare number or MCP card. 1.1.2 If the patient is an outpatient , confirm positive identification using MCP or facility identification or unique identifier. This identification shall be identical to the requisition. Verbal confirmation must be obtained ; 1.1.2.1 The patient must state his/her first and last name and date of birth prior to collecting specimen; or 1.1.2.2 I dentify the patient as per f acility policy i f the patient is unable to communicate . 1.1.3

If the patient is an inpatient, confirm positive identification using MCP or facility identificat ion or unique identi fier. Verbal confirmation shall be obtained if the patient is able to communicate. 1.1.4 A qualified person (patient care giver) shall positively identify the patient and have the identification band attached to the patient prior to collectio n , as per facility policy , i f the patient is an inpatient or patient admitted to emergency and does not have an identification band. 1.1.5 The patient shall be positively identified by a qualified person , as per facility policy , i f a patient identification band cannot be physically placed on the patient . 1.2 In e mergencies and other situations where the patient’s identification is unknown , facility procedure for positive pat ient identification shall be followed. 1.3 Blood specimen labels shall include the date and time of collection and be initialled /signed by the healthcare professional collecting the specimen . The identity of the phlebotomist must be traceable back to the collected specimen . 1.4 Handwritten labels shall be completed using indelible ink . Provincial Blood Coordinating Program _______________________________________________________________________ This document may be in

corporated into each Regional Policy/ Procedure Manual. NL2010 . - 014 Version: 3.0 Effective Date: 20 15 - 05 - 14 Page 3 of 7 Guidelines for Patient Identific ation and Labeling of Pre - transfusion Specimens 1.5 On ly qualified healthcare professionals trained in blood collection shall collect specimens . 1.6 The phlebotomist shall label each blood specimen tube in the presence of the patient . 1.7 Changes to patient identification shall not be made after the original requisition and specimen label are received by the transfusion medicine laboratory. 1.8 The Transfusion Medicine (TM) lab oratory shall not process specimens or requests that are incomplete, incorrect or illegib le . 2.0 Linkages Guidelines for Transfusion Orders for Blood Components and Blood Products . Available at: http://www.health.gov.nl.ca/health/bloodservices/pdf/transfusion_orders_version_2.pdf 3.0 S cope 3.1 All health care professionals who participate in the collection and labeling of pre - transfusion blood samples. 3.2 All medical laboratory professionals who ensure specimen acceptability. 4.0 General Information (N/A) 5.0 Process 5.1 Quality Control 5.1.1 If errors or discrepancies are detected in the identification of recipients of blood compon

ents or blood products and/or specimen labelling , they must be documented in an incident / occurrence report according to facility procedure. Corrective measures must be taken and documented . Provincial Blood Coordinating Program _______________________________________________________________________ This document may be incorporated into each Regional Policy/ Procedure Manual. NL2010 . - 014 Version: 3.0 Effective Date: 20 15 - 05 - 14 Page 4 of 7 Guidelines for Patient Identific ation and Labeling of Pre - transfusion Specimens 5.1.2 Internal audits may be performed to ensure phlebotomist identity and the date and time of collection have been documented. 5.2 Procedure 5.2.1 Confirm patient identification using the patient ’s identification band (when applicable) or by verbal confirmation (outpatients) whereby the patient is asked to state their name and date of birth. NOTE: All patients who are able to provide verbal confirmation of identity are asked to state their name and date of birth even if they are wearing an armband. 5.2.2 Compare the patient’s name and unique identification number on the patient’s identification band (when applicable) or MCP/hospital card with the inf ormation on the requisition and/ or computer gene

rated labels. The patient’s name and un ique identi fication number must be identical . 5.2.3 Ensure any discrepancy in patient identification is resolved before performing venipuncture . 5.2.4 Collect blood specimen (venipuncture, central venous access devices) as per facility procedure. 5.2.5 Label specimen(s) immediately after collection in the presence of the patient . The date, time and identification of the healthcare professional co llecting the specimen must be documented on the label before leaving the patient’s side . 5.2.6 Perform a final check before leaving the patient’s side to ensure that all information is identical on : 5.2.6.1 Specimen tube labels ; 5.2.6.2 Requisition if required by the facility ; and 5.2.6.3 Patient identifier . 5.2.7 Deliver specimen to transfusion medicine laboratory. 5.3 Guidelin es (N/A) Provincial Blood Coordinating Program _______________________________________________________________________ This document may be incorporated into each Regional Policy/ Procedure Manual. NL2010 . - 014 Version: 3.0 Effective Date: 20 15 - 05 - 14 Page 5 of 7 Guidelines for Patient Identific ation and Labeling of Pre - transfusion Specimens 5.4 Materials (N/A) 6.0 Acronyms TM

Transfusion Medicine PPI Positive Patient Identification 7.0 Definitions venipuncture surgical puncture of a vein especially for the withdrawal of blood or for intravenous medication phlebotomist health worker trained in drawing venous blood for testing or donation 8.0 Records Management 8.1 All transfusion records in the recipient’s medical chart shall be retained in accordance with health care facility’s retention policy for medical records . 8.2 The patient’s transfu sion data file in the Transfusion Medicine Laboratory shall be retained indefinitely . 8.3 Healthcare employee signatures, initials and computer identification shall be retained for ten years 8.4 Documentation of staff qualifications, training and competency must be retained for ten years . 8.5 Date and t ime a sample was drawn and phlebotomist identification must be retained for one year . 8.6 Serological test requests for transfusion must be kept for one month or as per facility policy. Provincial Blood Coordinating Program _______________________________________________________________________ This document may be incorporated into each Regional Policy/ Procedure Manual. NL2010 . - 014 Version: 3.0 Effective Date: 20 15 - 05 - 14 Page 6 of 7 Gu

idelines for Patient Identific ation and Labeling of Pre - transfusion Specimens 9.0 Key Words P ositive Patient Identification Provincial Blood Coordinating Program _______________________________________________________________________ This document may be incorporated into each Regional Policy/ Procedure Manual. NL2010 . - 014 Version: 3.0 Effective Date: 20 15 - 05 - 14 Page 7 of 7 Guidelines for Patient Identific ation and Labeling of Pre - transfusion Specimens References Canadian Society for Transfusion Medicine. (2011). Standards for hospital transfusion services . (Version 3.0.). Ottawa, ON: Author. Canadian Standards Association. (2010). Blood and blood components, Z902 - 10 . Mississauga, ON: Author. Downes, K.A., Shulman, I.A. (2014). Pretransfusion Testing. In M. K. Fung, B. J. Grossman, C. D. Hillier, & C. M. Westhoff (Eds.), AABB (18th ed., pp. 367 - 370). Bethesda, MD: AABB Press Maynard, K. (2014). Administration of Blood Components. In M. K. Fung, B. J. Grossman, C. D. Hillier, & C. M. Westhoff (Eds.), AABB (18th ed., pp. 547). Bethesda, MD: AABB Press Ontario Regional Blood Coordinating Network. (201 1). Bloody Easy 3: Transfusion Basics, pp. 15. Ottawa ON: Autho