Form 57.300 Hemovigilance Module Annual Survey

OMB No. 0920-0666

Exp. Date: XX-XX-XXXX

Hemovigilance Module

Annual Facility Survey

*Required for saving

*Facility ID#: ____________________

*Survey Year: ____________

For all questions, use information from last full calendar year.

Facility Characteristics

*1. Ownership: (check one)

Government

Military

Not for profit, including church

For profit

Veteran’s Affairs

Managed Care Organization

Physician-owned

*2. Is your hospital affiliated with a medical school?

Yes

No

If Yes, check type of affiliation:

Major

Graduate

Limited

3. Community setting of facility:

Urban

Suburban

Rural

*4. How is your hospital accredited? (check one)

National Integrated Accreditation for Healthcare Organizations (DNV)

The Joint Commission

American Osteopathic Association (AOA)

Other Accrediting Organization

*5. Total beds served by Transfusion Services.

___________

*6. Number of surgeries performed per year:

Inpatient:

_______

Outpatient:

_______

*7. At what trauma level is your facility certified?

I

II

III

IV

N/A

Transfusion Services Characteristics

*8. Primary classification of facility areas served by Transfusion Services: (check all that apply)

General medical and surgical

Obstetrics and gynecology

Orthopedic

Cancer center

Chronic disease

Children’s general medical and surgical

Children’s orthopedic

Children’s cancer center

Children’s chronic disease

Other (specify) _________________

*9. Does your healthcare facility provide all of its own transfusion services, including all laboratory functions?

Yes

No, we contract with a blood center for some transfusion service functions.

No, we contract with another healthcare facility for some transfusion service functions.

*10. Is your Transfusion Services part of the facility’s core laboratory?

Yes

No

*11. How many dedicated Transfusion Services staff members are there?

Number of technical FTEs (including supervisors)

________

Number of dedicated physician FTEs:

_____

Number of MLTs:

_____

Number of MTs:

_____

Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333 ATTN: PRA (0920-0666).

*12. Does your hospital have a dedicated position or FTE in a quality or patient safety department/function for investigation of transfusion-related adverse reactions?

Yes

No

*13. Does your hospital have a dedicated position or FTE in a quality or patient safety department/function for investigation of transfusion errors (i.e. incidents)?

Yes

No

*14. Is your Transfusion Services laboratory accredited?

Yes

No

If Yes, select all that apply:

College of American Pathologists (CAP)

AABB

*15. Do you have a committee that reviews blood utilization?

Yes

No

*16. Total number of samples collected:

________

*17. Products and total number of units/aliquots transfused: (check all that apply)

Units:

Aliquots:

Whole blood derived red blood cells

________

________

Apheresis red blood cells

________

________

Whole blood derived platelet concentrates

________

N/A

What is your average pool size?

________

Apheresis platelets

________

________

Whole blood derived plasma (Incl. FFP, thawed, etc.)

________

________

Apheresis plasma

________

________

Cryoprecipitate

________

N/A

Granulocytes

________

________

Lymphocytes

________

________

*18. Are any of the following administered through Transfusion Services? (check all that apply)

Albumin

Factors (VIIa, VIII, IX, ATIII, etc)

Immunoglobulin (IV)

Immunoglobulin (IM or subcutaneous)

RhIg

None

*19. Does your facility attempt to transfuse only leukocyte-reduced cellular components?

Yes

No

*20. Are all units stored in the Transfusion Services area?

Yes

No

If No, indicate the location(s) of satellite storage: (check all that apply)

Operating Room

Emergency Room

Ambulatory Care

Other: (specify) __________________________________________

*21. To what extent does Transfusion Services modify products? (check all that apply)

Aliquot

Deglycerolizing

Irradiation

Leukoreduction

Plasma reduction

Pooling

Washing

None of these

*22. Do you collect blood for transfusion at your facility?

Yes

No

If Yes, check all that apply:

Allogeneic

Autologous

Directed

*23. Does your facility perform viral testing on blood for transfusion?

Yes

No

24. Units/Aliquots Transfused by Department or Service: (optional)

Department/ Service

Samples Collected

Units/Aliquots Transfused

Platelets

Red Blood Cells

Plasma

Cryoprecipitate

Granulocytes

Lymphocytes

Whole Blood Derived

Apheresis

Whole Blood Derived

Apheresis

Whole Blood Derived

Apheresis

Emergency Room/ Trauma

Units

Aliquots

Hematology/ Oncology (BMT/Aph)

Units

Aliquots

ICU/NICU

Units

Aliquots

Nephrology/ Dialysis

Units

Aliquots

Obstetrics/ Gynecology

Units

Aliquots

Pediatrics/ Neonatology*

Units

Aliquots

Surgery, Cardiac

Units

Aliquots

Surgery, General

Units

Aliquots

Surgery, Orthopedic

Units

Aliquots

Surgery, Other

Units

Aliquots

Solid Organ Transplant

Units

Aliquots

General Medical, Other

Units

Aliquots

*Non-Pediatric Facilities Only

Transfusion Services Computerization

*25. Is Transfusion Services computerized?

Yes

No (If No, skip to next section)

If Yes, select system(s) used: (check all that apply)

Cerner Classic®

Cerner Millennium®

HCLL®

Horizon BB®

Hemocare®

Lifeline®

Meditech®

Misys®

Wyndgate® (Safetrace TX)

Softbank®

Western Star®

Other (specify) __________________________________________

*26. Is your system ISBT-128 compliant?

Yes

No

*27. Does the Transfusion Services system interface with the patient registration system?

Yes

No

*28. Are Transfusion Services adverse events entered into a hospital-wide electronic reporting system?

Yes

No

If Yes, specify system used: ________________________________

*29. Do you use positive patient ID technology for transfusion services?

Yes, hospital wide

Yes, certain areas

Not used

If Yes, select purpose(s): (check all that apply)

Specimen collection

Product administration

If Yes, select system(s) used: (check all that apply)

Mechanical barrier system (e.g., Bloodloc®)

Separate transfusion ID wristband system (e.g., Typenex®)

Radio frequency identification (RFID)

Bedside ID band barcode scanning

Other (specify) ____________________________________________________________

*30. Do you have physician online order entry for test requesting?

Yes

No

*31. Do you have physician online order entry for product requesting?

Yes

No

Transfusion Services Specimen Handling and Testing

*32. Are Transfusion Services specimens drawn by a dedicated phlebotomy team?

Always

Sometimes, approximately _______% of the time

Never

*33. What specimen labels are used at your facility? (check all that apply)

Handwritten

Addressograph

Computer generated from laboratory test request

Computer generated by bedside device

Other (specify) _______________________

*34. Are phlebotomy staff members allowed to correct patient identification errors on pre-transfusion specimen labels?

Yes

No

*35. What items can be used to verify patient identification during specimen collection and prior to product administration at your facility? (check all that apply)

Medical record (or other unique patient ID) number

Date of birth

Gender

Patient first name

Patient last name

Transfusion specimen ID system (e.g., Typenex®)

Patient verbal confirmation of name or date of birth

Other (specify) ____________________

*36. How are routine type and screen done? (check all that apply and estimate frequency of each)

Manual technique

_______%

Automatic technique

_______%

Both automatic and manual technique

_______%

Total should equal 100%

*37. Is the ABO group of a pre-transfusion specimen routinely confirmed?

Yes

No

If Yes, check one:

All samples

If there is no laboratory record of previous determination of patient’s ABO group

If there is no laboratory record of previous determination of patient’s ABO group AND the patient is a candidate for electronic crossmatching

If Yes, is the confirmation required on a separately-collected specimen before a unit of Group A, B, or AB red blood cells is issued for transfusion?

Yes

No

*38. How many RBC type and screen and crossmatch procedures were performed at your facility by any method?

RBC type and screen:

________

RBC crossmatch

________

Estimate the % of crossmatch procedures done by each method: (check all that apply)

Electronically

_____%

Serologically

_____%

Don’t know

Total may be >100%

CDC 57.300 Rev. 1, v6.4

Page 5 of 5