Volume 2024 | No. 2
SURVEYOR
CLINICAL LABORATORY
NOTES
CHAPTER 8: IMMUNOHEMATOLOGY AND TRANSFUSION SERVICES 08.02.01 Temperature Alarm System
Overview of the requirement:
A 24-hour audible alarm system is required for temperature controlled storage of blood and blood products. The alarm system is monitored daily for proper functioning. Compliance is assessed through observation, interview, and document review. Most deficiencies were cited when alarm activation was at variance with identified safe ranges for the products stored. Other observations included allowing a temperature range that extends beyond the recommended limits.
Comment on deficiencies:
Frequency of citation:
22%
Examples of surveyor findings:
n Room temperature was not documented every four hours when platelets were being stored as per laboratory policy. n Alarm activation records showed that the platelet incubator activated at 19.8 degrees and 24.2 degrees on [date], 19.8 degrees and 24.6 degrees on [date], 19.9 degrees and 24.5 degrees on [date], and the plasma freezer at -17.0 degrees [date]. These activation temperatures are all outside of the acceptable storage ranges for those products. n The log used for the blood storage refrigerator listed an upper temperature limit of 8° Celsius that does not comply with the upper limit of 6°C allowed for blood storage. Actual temperatures had not exceeded 6°C. n Review storage requirements for blood and blood products and ensure that policies and logs reflect the relevant guidelines. n Check accuracy of alarm settings. Conduct daily monitoring of alarms for ongoing function. n Log room temperatures for platelet storage within strict time frames.
Tips for compliance:
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
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