Form Approved
OMB
No. 0920-0666
Exp. Date: 12/31/22
www.cdc.gov/nhsn
Hemovigilance Module - Annual Facility Survey
Non-Acute Care Facility
*Required for saving
*Facility ID#: ____________________ |
*Survey Year: ____________ |
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For all questions, use information from previous full calendar year. |
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Facility Characteristics |
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*1. Ownership: (check one) |
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Government |
Military |
Not for profit, including church |
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For profit |
Veteran’s Affairs |
Physician-owned |
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*2. Community setting of facility: |
Urban |
Suburban |
Rural |
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*3. Total number of operating rooms at time of survey completion: |
___________ |
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*4. Total number of procedure rooms at time of survey completion: |
___________ |
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*5. Total number of patient admissions in this survey year: |
___________ |
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*6. Check all the specialty(ies) currently performed in your facility: |
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Bariatrics |
General surgery |
Gastroenterology |
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Gynecology |
Neurology |
Orthopedic |
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Plastic surgery |
Spine |
Urology |
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Other (specify) ________________________ |
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Transfusion Service Characteristics |
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*7. Does your facility provide all of its own transfusion services, including all laboratory functions? |
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Yes |
No, we contract with a blood center for some transfusion service functions. |
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No, we contract with another healthcare facility for some transfusion service functions. |
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No, we contract with another blood center for all transfusion service functions. |
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No, we contract with another healthcare facility for all transfusion service functions. |
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*8. How many dedicated transfusion service staff members are there? (Count full-time equivalents; include supervisors.) |
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Physicians: |
____ |
Medical Technologists: |
_____ |
Medical Laboratory Technicians: |
_____ |
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*9. Does your facility have a dedicated position or FTE in a quality or patient safety function (e.g., TSO) for investigation of transfusion-related adverse reactions? |
Yes |
No |
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*10. Does your facility have a dedicated position or FTE in a quality or patient safety function (e.g., TSO) for investigation of transfusion errors (i.e., incidents)? |
Yes |
No |
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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 35 minutes 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).
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Transfusion Service Characteristics (continued) |
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*11. Does your facility have a committee that reviews blood utilization? |
Yes |
No |
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*12. Total number of patient samples collected for type and screen or crossmatch: ________ |
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*13. Does your facility perform point-of-issue bacterial testing on platelets prior to transfusion? |
Yes |
No |
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Transfusion Service Computerization |
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*14. Is the transfusion service computerized? |
Yes |
No (If No, skip to question 17) |
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If Yes, select system(s) used: (check all that apply) |
BBCS® |
BloodTrack Tx® (Haemonetics) |
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Cerner Classic® |
Cerner Millennium® |
HCLL® |
Horizon BB® |
Hemocare® |
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Lifeline® |
Meditech® |
Misys® |
Safetrace Tx® (Haemonetics) |
Softbank® |
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Western Star® |
Other (specify) __________________________________________ |
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*15. Is the system ISBT-128 compliant? |
Yes |
No |
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*16. Does the transfusion service system interface with the patient registration system? |
Yes |
No |
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*17. Does your facility use positive patient ID technology for transfusion? |
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Yes, facility wide |
Yes, certain areas |
Not used |
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If Yes, select purpose(s): (check all that apply) |
Specimen collection |
Product administration |
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If Yes, select system(s) used: (check all that apply) |
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Mechanical barrier system (e.g., Bloodloc®) |
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Separate transfusion ID wristband system (e.g., Typenex®) |
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Radio frequency identification (RFID) |
Bedside ID band barcode scanning |
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Other (specify) ____________________________________________________________ |
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Transfusion Service Specimen Handling and Testing |
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*18. Are transfusion service specimens drawn by a dedicated phlebotomy team? |
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Always |
Sometimes, approximately _______% of the time |
Never |
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*19. What specimen labels are used at your facility? (check all that apply) |
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Handwritten |
Addressograph |
Computer generated from laboratory test request |
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Computer generated by bedside device |
Other (specify) _______________________ |
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*20. Are phlebotomy staff members allowed to correct patient identification errors on pre-transfusion specimen labels? |
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Yes |
No |
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*21. What items can be used to verify patient identification during specimen collection and prior to product administration at your facility? (check all that apply) |
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Medical record (or other unique patient ID) number |
Date of birth |
Gender |
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☐Sex at Birth ☐Gender Identity Patient first name |
Patient last name |
Transfusion specimen ID system (e.g., Typenex®) |
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Patient verbal confirmation of name or date of birth |
Other (specify) ____________________ |
CDC 57.306 v1, R8.6
Page
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | 57.300_HV Annual Survey |
Subject | NHSN OMB Forms 2020 |
Author | CDC/NCEZID/DHQP |
File Modified | 0000-00-00 |
File Created | 2023-09-03 |