Form 57.306 Hemovigilance Module Annual Survey - Non-acute Care Faci

Form Approved

OMB No. 0920-xxxx

Exp. Date: XX/XX/20XX

www.cdc.gov/nhsn

Hemovigilance Module - Annual Facility Survey

Non-Acute Care Facility

*Required for saving

*Facility ID#: ____________________

*Survey Year: ____________

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

Facility Characteristics

*1. Ownership: (check one)

Government

Military

Not for profit, including church

For profit

Veteran’s Affairs

Physician-owned

*2. Community setting of facility:

Urban

Suburban

Rural

*3. Total number of operating rooms at time of survey completion:

___________

*4. Total number of procedure rooms at time of survey completion:

___________

*5. Total number of patient admissions in this survey year:

___________

*6. Check all the specialty(ies) currently performed in your facility:

Bariatrics

General surgery

Gastroenterology

Gynecology

Neurology

Orthopedic

Plastic surgery

Spine

Urology

Other (specify) ________________________

Transfusion Service Characteristics

*7. Does your 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.

No, we contract with another blood center for all transfusion service functions.

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

*8. How many dedicated transfusion service staff members are there? (Count full-time equivalents; include supervisors.)

Physicians:

____

Medical Technologists:

_____

Medical Laboratory Technicians:

_____

*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

*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

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). CDC 57.306 R0, v8.6

Hemovigilance Module - Annual Facility Survey

Non-Acute Care Facility

Transfusion Service Characteristics (continued)

*11. Does your facility have a committee that reviews blood utilization?

Yes

No

*12. Total number of patient samples collected for type and screen or crossmatch: ________

*13. Does your facility perform point-of-issue bacterial testing on platelets prior to transfusion?

Yes

No

Transfusion Service Computerization

*14. Is the transfusion service computerized?

Yes

No (If No, skip to question 17)

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

BBCS®

BloodTrack Tx® (Haemonetics)

Cerner Classic®

Cerner Millennium®

HCLL®

Horizon BB®

Hemocare®

Lifeline®

Meditech®

Misys®

Safetrace Tx® (Haemonetics)

Softbank®

Western Star®

Other (specify) __________________________________________

*15. Is the system ISBT-128 compliant?

Yes

No

*16. Does the transfusion service system interface with the patient registration system?

Yes

No

*17. Does your facility use positive patient ID technology for transfusion?

Yes, facility 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) ____________________________________________________________

Transfusion Service Specimen Handling and Testing

*18. Are transfusion service specimens drawn by a dedicated phlebotomy team?

Always

Sometimes, approximately _______% of the time

Never

*19. 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) _______________________

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

Yes

No

*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)

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) ____________________

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