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Posted: Mar. 12, 2002

Addenda: Mar. 13, 2002


Documenting disposal of blood removed by therapeutic phlebotomy

A blood banker reports that at a certain hospital all therapeutic phlebotomy is done by nursing staff and that the therapeutic phlebotomy blood is disposed of, and NOT used for any other purpose. The mechanism for disposal is to bring the blood to the lab for disposal. Before disposing of the blood, the lab maintains a log with a copy of the physician's order, patient demographics, and the volume of the phlebotomy. The inquiring blood banker believes that this facility is in compliance, but does not cite a specific authority, rule or regulation. The inquiring blood banker admits that the nursing procedure needs a revision to require that the physician's order for a therapeutic phlebotomy should specify the amount of blood to be taken at the time of phlebotomy, and that the policy will be revised accordingly. Now comes the question. If all laboratory involvement in this process is eliminated, and if nursing service disposes off the unit, (i.e. lab. is not involved at all), does the hospital have any obligation to document the information that has been collected routinely (as described above) by the laboratory? In other words, is there any requirement for a clear audit trail of therapeutic phlebotomies that take place in a hospital or outpatient setting? If so, by what authority and what is the rule/regulation?

The following responses have been received.

  1. A blood banker in Texas wrote that their therapeutic phlebotomies are done in their Outpatient Oncology Room where they also do outpatient transfusions. The nurses are cross-trained in giving transfusion and in taking therapeutic phlebotomy. The nurses use a scale that the lab calibrates each time of use to draw off the volume of blood requested by the patient's physician. The nurse then disposes of the blood into biohazard trash. There is no log kept. The Texan reports that the JCAHO and CAP have not cited her facility for this practice in the past, but she did not indicate if either the CAP or the JCAHO had specifically commented on the practice and said that it was alright.

ADDENDA March 13, 2002

  1. A California blood banker commented that it would seem a good idea to specify a maximum amount which could be drawn at the time of phlebotomy. She admits that she has seen (misguided) physicians request more than one unit be "taken off" in a single session.

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