Form CDC 57.302 CDC 57.302 Hemovigilance Module Monthly Incident Summary

[NCEZID] The National Healthcare Safety Network (NHSN)

57.302_hv-monthly-incident-summary_NB-Clean Version

Hemovigilance Module Monthly Incident Summary

OMB: 0920-0666

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Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026 www.cdc.gov/nhsn

Hemovigilance Module

Monthly Incident Summary


*Required for saving


*Facility ID#: _______________

*Month: ______________

*Year: ______________

All reporting is facility-wide. Include numbers of individual incident reports in the totals.


*Process Code

*Incident Code

*Total

Incidents

*Total Adverse Reactions

PC: Product Check-In

(Transfusion Service)

Events that occur during the shipment and receipt of products into the transfusion service from the supplier, another hospital site, satellite storage, or clinical area.

PC 00 Detail not specified



PC 01 Data entry incomplete/incorrect/not performed



PC 02 Shipment incomplete/incorrect



PC 03 Products and paperwork do not match



PC 04 Shipped/transported under inappropriate conditions



PC 05 Inappropriate return to inventory



PC 06 Product confirmation incorrect/not performed



PC 07 Administrative check not incorrect/not performed (record review/audit)



PC 08 Product label incorrect/missing



US: Product Storage

(Transfusion Service)

Events that occur during product storage by the transfusion service.

US 00 Detail not specified



US 01 Incorrect storage conditions



US 03 Inappropriate monitoring of storage device



US 04 Unit stored on incorrect shelf (e.g., ABO/autologous/directed)



US 05 Incorrect storage location



IM: Inventory Management

(Transfusion Service)

Events that involve quality management of the blood product inventory.

IM 00 Detail not specified



IM 01 Inventory audit incorrect/not performed



IM 02 Product status incorrectly/not updated online (e.g., available/discarded)



IM 03 Supplier recall/traceback not appropriately addressed/not performed



IM 04 Product order incorrectly/not submitted to supplier



IM 05 Outdated product in available inventory



IM 06 Recalled/quarantined product in available inventory



PR: Product/Test Request

(Clinical Service)

Events that occur when the clinical service orders patient tests or blood products for transfusion.

PR 00 Detail not specified



PR 01 Order for wrong patient



PR 02 Order incompletely/incorrectly ordered (online order entry)



PR 03 Special processing needs not indicated (e.g., CMV negative, autologous)



PR 04 Order not done



PR 05 Inappropriate/unnecessary (intended) test ordered



PR 06 Inappropriate/unnecessary (intended) blood product ordered



PR 07 Incorrect (unintended) test ordered



PR 08 Incorrect (unintended) blood product ordered



OE: Product/Test Order Entry

(Transfusion Service)

Events that occur when the transfusion service receives a patient order. This process may be excluded if clinical service uses online ordering.

OE 00 Detail not specified



OE 01 Order entered for wrong patient



OE 02 Order incompletely/incorrectly entered online



OE 03 Special processing needs not entered (e.g., CMV-, autologous)



OE 04 Order entry not done



OE 05 Inappropriate/unnecessary (intended) test order entered



OE 06 Inappropriate/unnecessary (intended) blood product order entered



OE 07 Incorrect (unintended) test ordered



OE 08 Incorrect (unintended) blood product ordered



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 30 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 H21-8, Atlanta, GA 30333, ATTN: PRA (0920-0666).


*Process Code

*Incident Code

*Total

Incidents

*Total Adverse Reactions

SC: Sample Collection

(Service collecting the samples)

Events that occur during patient sample collection.


SC 00 Detail not specified



SC 01 Sample labeled with incorrect patient ID (intended patient drawn)



SC 02 Sample not labeled



SC 03 Wrong patient collected (sample labeled for intended patient)



SC 04 Sample collected in wrong tube type



SC 05 Sample quantity not sufficient (QNS)



SC 06 Sample hemolyzed



SC 07 Sample label incomplete/illegible for patient identifiers



SC 08 Sample collected in error (e.g., unnecessary/duplicate)



SC 09 Patient sample not collected (in error)



SC 10 Patient wristband incorrect/not available



SC 11 Sample contaminated



SH: Sample Handling

(Service collecting the samples)

Events that occur when a patient sample is sent for testing.

SH 00 Detail not specified



SH 01 Sample sent without requisition



SH 02 Requisition and sample label don’t match



SH 03 Patient ID incomplete/illegible on requisition



SH 04 No Patient ID on requisition



SH 05 No phlebotomist/witness identification



SH 06 Sample sent with incorrect requisition type



SH 07 Patient information (other than ID) missing/incorrect on requisition



SH 08 Requisition sent without sample



SH 09 Data entry incorrect/incomplete/not performed



SH 10 Sample transport issue (e.g., sample broken/inappropriate conditions)



SH 11 Duplicate sample sent in error



SR: Sample Receipt

(Transfusion Service)

Events that occur when a sample is received by the transfusion service.

SR 00 Detail not specified



SR 01 Sample accepted in error



SR 02 Historical review incorrect/not performed



SR 03 Demographic review/ data entry incorrect/not performed



SR 04 Sample incorrectly accessioned



ST: Sample Testing

(Transfusion Service)

Events that occur during patient sample testing by the transfusion service.

ST 00 Detail not specified



ST 01 Data entry incomplete/incorrect/not performed



ST 02 Appropriate sample checks incomplete/incorrect/not performed



ST 03 Computer warning overridden in error or outside SOP



ST 05 Sample test tube incorrectly accessioned



ST 07 Sample test tubes mixed up



ST 09 Sample test tube mislabeled (wrong patient identifiers)



ST 10 Equipment problem/failure/not properly QC’d



ST 12 Sample testing not performed



ST 13 Incorrect sample testing method chosen



ST 14 Sample testing performed incorrectly



ST 15 Sample test result misinterpreted



ST 16 Reagents used were incorrect/inappropriate/expired/not properly QC’d



ST 17 ABO/Rh error caught on final check



ST 18 Current/historical ABO/Rh mismatch



ST 19 Additional testing not performed



ST 20 Confirmatory check incorrect/not performed (at time work performed)



ST 21 Administrative check incorrect/not performed (record review/audit)



ST 22 Sample storage incorrect/inappropriate








*Process Code

*Incident Code

*Total

Incidents

*Total Adverse Reactions

UM: Product Manipulation/

Processing/Testing

(Transfusion Service)

Events that occur while testing, manipulating (e.g., pooling, washing, aliquoting, irradiating), processing, or labeling blood products.

UM 00 Detail not specified



UM 01 Data entry incomplete/incorrect/not performed



UM 02 Record review incomplete/incorrect/not performed



UM 03 Incorrect product (type) selected



UM 04 Incorrect product (patient) selected



UM 05 Product labeled incorrectly (new/updated)



UM 06 Computer warning overridden in error or outside SOP



UM 07 Special processing needs not checked



UM 08 Special processing needs misunderstood or misinterpreted



UM 09 Special processing needs performed incorrectly



UM 10 Special processing needs not performed



UM 11 Equipment problem/failure/not properly QC’d



UM 12 Reagents used were incorrect/inappropriate/expired/not properly QC’d



UM 13 Confirmatory check incorrect/not performed (at time work performed)



UM 14 Administrative check incorrect/not performed (record review/audit)



No Blood

NB 01 Inventory less than usual par level due to supplier unable to meet usual steady demand



NB 02 Demand for blood product exceeding usual par inventory level



NB 03 Incompatible/inappropriate units issued due to inventory constraints when demand for blood product exceeds usual par inventory levels.



NB 04 Suboptimal dose (less than optimal quantity) transfusion or no transfusion due to inventory constraints when demand for blood product exceeds usual par inventory levels.



RP: Request for Pick-Up

(Clinical Service)

Events that occur when the clinical service requests pick-up of a blood product from the transfusion service.

RP 00 Detail not specified



RP 01 Request for pick-up on wrong patient



RP 02 Incorrect product requested for pick-up



RP 03 Product requested prior to obtaining consent



RP 04 Product requested for pick-up, but patient not available



RP 05 Product requested for pick-up, but IV not ready



RP 06 Request for pick-up incomplete (e.g., patient ID/product type missing)



RP 07 Pick-up slip did not match patient information on product



UI: Product Issue

(Transfusion Service)

Events that occur when the transfusion service issues blood product to the clinical service.

UI 00 Detail not specified



UI 01 Data entry incomplete/incorrect/not performed



UI 02 Record review incomplete/incorrect/not performed



UI 03 Product issued for wrong patient



UI 04 Product issued out of order



UI 05 Product issue delayed



UI 06 LIS warning overridden in error or outside SOP



UI 07 Computer issue not completed



UI 08 Issued visibly defective product (e.g., clots/aggregates/particulate matter)



UI 09 Not/incorrect checking of unit and/or patient information



UI 10 Product transport issues (e.g., delayed) by transfusion service



UI 11 Unit delivered to incorrect location by transfusion service



UI 12 Product transport issue (from transfusion service to clinical area)



UI 18 Wrong product issued for intended patient (e.g., incompatible)



UI 19 Inappropriate product issued for patient (e.g., not irradiated, CMV+)



UI 20 Confirmatory check incorrect/not performed (at time work performed)



UI 21 Administrative check incorrect/not performed (record review/audit)



UI 22 Issue approval not obtained/documented



UI 23 Receipt verification not performed (pneumatic tube issue)







*Process Code

*Incident Code

*Total

Incidents

*Total Adverse Reactions

CS: Satellite Storage

(Clinical Service)

Events that occur while product is stored and handled by the clinical service.

CS 00 Detail not specified



CS 01 Incorrect storage conditions of product in clinical area



CS 02 Incorrect storage location in the clinical area



CS 03 Labeling issue (by clinical staff)



CS 04 Floor/clinic did not check for existing products in their area



CS 05 Product transport issues (to or between clinical areas)



CS 06 Monitoring of satellite storage incorrect/incomplete/not performed



CS 07 Storage tracking/documentation incorrect/incomplete/not performed



UT: Product Administration

(Clinical Service)

Events that occur during the administration of blood products.

UT 00 Detail not specified


UT 01 Administered intended product to wrong patient



UT 02 Administered wrong product to intended patient



UT 03 Transfusion not performed in error



UT 05 Bedside check (patient ID confirmation) incomplete/not performed



UT 06 Transfused product with incompatible IV fluid



UT 07 Transfusion delayed beyond pre-approved timeframe



UT 09 Transfused unsuitable product (e.g., outdated/inappropriately stored)



UT 10 Administered components in wrong order


UT 11 Appropriate monitoring of patient not performed



UT 14 Transfusion volume too low (per order or SOP)



UT 15 Transfusion volume too high (per order or SOP)



UT 16 Transfusion rate too slow (per order or SOP)



UT 17 Transfusion rate too fast (per order or SOP)



UT 18 Inappropriate preparation of product



UT 19 Transfusion protocol not followed (not otherwise specified)



UT 22 Order/consent check incorrect/not performed



UT 23 Transfusion documentation incorrect/incomplete/not performed



UT 24 Transfusion documentation not returned to transfusion service



UT 26 Transfusion reaction protocol not followed



MS: Other

MS 99 Other




Total




CDC 57.302 Rev. 3, v8.1

Page 8 of 8

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.302_HV Monthly Incident
AuthorCDC
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File Created2024-07-24

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