SARASOTA MEMORIAL HOSPITAL POLICY
|
|
- Horace Kelley
- 5 years ago
- Views:
Transcription
1 PS1070 SARASOTA MEMORIAL HOSPITAL POLICY TITLE: BREAST MILK EXPOSURE POLICY #: EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: 5/23/06 06/15/18 Clinical Non-Clinical 1 of 11 Job Title of Responsible Owner: Director of Women and Children s Services PURPOSE: POLICY STATEMENT: To provide guidelines to health care workers in the event an infant/child is given the wrong breast milk. Sarasota Memorial Health Care System (SMHCS) provides a mechanism for reporting, medical evaluation and follow-up for exposure to the wrong breast milk. An occurrence report must be completed and physician notified. EXCEPTIONS: Due to the pasteurization and strict screening and testing of donor human milk purchased through the Human Milk Banking Association of North America, exposure of an infant to this donor human milk in error requires no medical follow up. DEFINITIONS: 1. Breast milk: synonymous with human milk or mother s milk or Expressed Breastmilk (EBM). 2. Recipient patient: patient who received the wrong mother s breast milk. 3. Recipient parent: parents of infant who received the wrong mother s breast milk. 4. Donor patient: patient whose mother s milk was inadvertently given to the wrong infant. 5. Donor mother: mother whose milk inadvertently was given to the wrong infant. 6. Communicator: Shift Charge Nurse PROCEDURE Potential treatment or intervention is time sensitive. Initiate this policy immediately after the exposure has occurred.
2 2 of 11 RESPONSIBILITY Responsibility of employee when wrong breast milk is given to infant/child 1. In the event that an infant/child received the wrong breast milk, the responsibility of the employee and communicator is to: a. Contact the clinical manager b. Contact the attending pediatrician, family practitioner, or neonatologist of the recipient infant/child c. Contact the attending obstetrician of the donor mother if she is still an admitted inpatient or d. Contact the attending pediatrician, family practitioner, or neonatologist of the donor infant/child. e. Contact the attending obstetrician of the recipient mother if she is still an admitted inpatient f. Draw ordered labs on recipient infant, recipient mother, and donor mother. Call Laboratory, ext to register in LIS. Never order in SCM. It will provide an account name; number and nomenclature specific for breast milk exposure lab use. This will assist in providing anonymity. g. Contact the director h. Contact the nursing supervisor i. Contact the risk manager on-call j. Contact the director of Laboratory or senior manager on-call The attending physicians of both the recipient infant/child and the donor mother will address parental concerns regarding the breast milk exposure while the recipient infant remains an inpatient at Sarasota Memorial Hospital. If the donor mother is not an admitted inpatient herself, then the attending physician of the donor infant/child will serve in this capacity. At the time of the recipient infant s discharge, the attending physician of the recipient infant/child will be responsible for referring this patient to the Pediatric Infectious Disease service at All Children s for outpatient follow-up. As soon as practical, promptly complete an Occurrence Report and submit to Risk Management. Responsibility of recipient infant/child patient s attending
3 3 of 11 physician 1. Communicates with the recipient parent(s). Documentation of the conversation with the recipient mother is to be placed in the recipient infant s electronic medical record and can be composed as in this example: Mother informed her baby received expressed breast milk from another mother. Discussed significance with her. a. Explain risk factors. b. Health history screen c. Notify that HIV test is planned for infant and mother. d. Order the following tests for the recipient patient AND his/her mother: 1) HIV 1 & 2 antibodies (if the recipient mother is HIV positive, HIV by PCR is ordered instead of HIV 1 &2 antibodies). 2) HTLV I & II antibodies 3) HBsAg 4) Hepatitis C antibody 5) RPR (Syphilis) 6) West Nile Virus Antibody Panel 7) CMV (infant/child only) The recipient mother will need to register with Outpatient Registration for labs to be drawn by SMH laboratory. Call Laboratory, ext to register in LIS. Never order in SCM. It will provide an account name; number and nomenclature specific for breast milk exposure lab use. This will assist in providing anonymity. e. Query recipient parent regarding suctioning gastric content of recipient patient. f. Prescribe post-exposure prophylaxis for recipient infant/child if positive risk factors are present or recipient parent chooses therapy. g. The donor infant/child or donor mother s names are not disclosed to the recipient parents and the recipient s parents names are not disclosed to the donor mother or donor parents. h. Results will be communicated by the Laboratory initially by phone and followed up with a hard copy to the: i. covering physician when the infant is still an in-
4 4 of 11 patient who will notify the recipient mother. ii. Pediatrician/Family Physician if the infant has been discharged who will notify the recipient mother. 2. Place a referral order at time of discharge for Pediatric Infectious Diseases for outpatient consultation. Include all of the following in the order: a All microbiology and immunology lab results are to be mailed, not faxed, b. All follow up lab work ordered by Infectious Disease physician must be done through SMH Special Procedures Lab (this is necessary so the patient does not get charged for follow up lab work). c. Infectious Disease physician/office must call to arrange lab appointment d. Billing of Infection Disease office visit must NOT be run through recipient s insurance. Send visit bill to SMH Risk Management. 3. Provide continuous communication and work in conjunction with Risk Management and director(s) to address concerns with the family. 4. Support and assist the patient and family as needed. Responsibility of donor mother s attending obstetrician OR when the donor mother is no longer an admitted inpatient, then the pediatrician, family practitioner, or neonatologist of the donor mother s infant/child. 1. Communicates with the donor mother. a. Explains risk factors b. Health history screen c. Notify donor mother that HIV test is planned d. Order the following tests for the donor mother.** 1) HIV 1 & 2 antibodies (if the recipient mother is HIV positive, HIV by PCR is ordered instead of HIV 1 &2 antibodies). 2) HTLV I & II 3) HBsAg 4) Hepatitis C antibody 5) RPR (Syphilis)
5 5 of 11 6) West Nile Virus Antibody Panel The donor mother will need to register with Outpatient Registration for labs to be drawn by SMH laboratory. Call Lab, ext to register in LIS. Never order in SCM. It will provide an account name; number and nomenclature specific for breast milk exposure lab use. This will assist in providing anonymity. e. The recipient infant/child and recipient parent names are not disclosed to the donor parents and the donor mother s name will not be disclosed to the recipient infant/child family. f Results of tests to donor mother will be communicated by the Laboratory initially by phone and followed up with a hard copy to the: i. covering physician, when the donor mother is still and in-patient, who will notify the donor mother. ii. Obstetrician, if the donor mother has been discharged, who will notify the donor mother. g. Support and assist the patient and family as needed. Responsibility of Director/Clinical Manager/Nursing Supervisor. 1. Assist in contacting Risk manager on-call, and the attending physician(s) 2. Director or Manager communicates incident to family. Communication with the family can be delegated to the charge nurse. 3. Contact Director of Laboratory Services ext. 6494, Preanalytical Manager, Laboratory Services (Outpatient Manager), ext and Special Chemistry Supervisor, ext Ensures the occurrence report is completed correctly. 5. Refer to Addendum A: Recommended Orders for Breast Milk Exposure Recipient Infant/Child Patient. 6. Refer to Addendum B: Recommended Orders for Breast Milk Exposure Donor Mother. 7. Refer to Addendum C: Recommended Orders for Breast
6 6 of 11 Milk Exposure Recipient s Mother. Responsibility of Laboratory Director: 1. Expedites lab results as stat lab orders. a. Results will be communicated by the Laboratory initially by phone and followed up with a hard copy to the: i. covering physician, when the infant is still an inpatient,who will notify the recipient mother. ii. Pediatrician/Family Physician, if the infant has been discharged, who will notify the recipient mother. iii. covering physician, when the donor mother is still an in-patient, who will notify the donor mother. iv. Obstetrician, if the donor mother has been discharged, who will notify the donor mother. 2. Assures that the LIS orders and the breast milk exposure labs are processed properly. 3. Ensures the anonymity of the recipient infant as well as the recipient and donor mothers during entire incident and all follow up testing. 4. Assists mothers without patient registration as needed REFERENCE(S): 00.RSK.60-Disclosure of Unanticipated Outcomes & Medical Errors to Patients and/or Their Legally Authorized Representative. American Academy of Pediatrics, Section on Breastfeeding [2012] Breastfeeding and the use of human milk. Pediatrics, Vol 129, No 3. American Association of Critical Care Nurses, AWHONN & NANN [2015]. Core Curriculum for Neonatal Intensive Care Nursing. Elsevier, Saunders, MO. Center for Disease Control and Prevention, Division of Nutrition, Physical Activity and Obesity. What can happen if someone else s breast milk is given to another child? Retrieved 10/10/15 from Hale, Thomas, Medications and Mother s Milk, 14 th Edition,
7 7 of 11 Amarillo: Hale Publishing Human Milk Banking Association of North America (2011). Best Practices for Expressing, Storing and Handling Human Milk in Hospitals, Homes and Child Care Settings, 3 rd ed. HMBABA, Inc. Lawrence, Ruth A. and Lawrence, Robert M., Breastfeeding, A Guide for the Medical Professions, 7 th Edition, Elsevier: Mosby, MO REVIEWED BY: AUTHOR(S): ATTACHMENT(S): Lyn Wakeman, Risk Management Clinician Sherry Wolabaugh, MT, MPH, CIC, Manager Infection Prevention & Control Laura Logan, Medical Technologist, Laboratory Services Katherine Wimbish, PharmD., Pediatric/NICU Clinical Pharmacist Jeannie Sleight, RN, CBC, Clinical Practice Specialist, MBU Susan Doyle, RNC, CLC, Clinical Coordinator, NICU Mary O Connor, MSN, RNC, IBCLC, Manager Childbirth Education & Lactation Services Heike Bucken, RNC-NCC, CLC, Clinical Coordinator NICU Addendum A: Recommended Orders for Breast Milk Exposure Recipient Infant/Child Patient. Addendum B: Recommended Orders for Breast Milk Exposure Donor Mother. Addendum C: Recommended Orders for Breast Milk Exposure Recipient Mother
8 8 of 11 SARASOTA MEMORIAL HEALTH CARE SYSTEM 1700 S. Tamiami Trail Sarasota, FL Addendum A: Recommended Orders for Breast Milk Exposure Recipient Patient Weight kg Allergies: Food Allergies: Check box for STAT medications l! Date Time RECOMMENDED ORDERS FOR BREAST MILK EXPOSURE Recipient Infant/Child Patient Labs: Rapid HIV if recipient mother is HIV negative OR HIV by Qualitative PCR if Recipient Mother is HIV positive Mnemonics R HIV HIV Q HTLV I & II antibody HbsAg (Hepatitis B Surface Antigen) Hepatitis C antibody Reflex to HCV PCR if (+) HCV Ab RPR (Syphilis) CMV West Nile Virus Antibody Panel ELISA (Test name in comment field) LAB HBSAG HCV RPR CMVG, CMVM WN Suction gastric contents of recipient infant? Yes No Please contact physician for post exposure prophylaxis and consult Pharmacy if needed. Addendum A: Recommended Orders for Breast Milk Exposure Recipient Infant/Child Patient
9 9 of 11 SARASOTA MEMORIAL HEALTH CARE SYSTEM 1700 S. Tamiami Trail Sarasota, FL Addendum B: Recommended Orders for Breast Milk Exposure Donor Mother Weight kg Allergies: Food Allergies: Check box for STAT medications l! Date Time RECOMMENDED ORDERS FOR BREAST MILK EXPOSURE Donor Mother Labs: Rapid HIV if recipient mother is HIV negative OR HIV by Qualitative PCR if Recipient Mother is HIV positive Mnemonics R HIV HIV Q HTLV I & II antibody HBsAg (Hepatitis B Surface Antigen) Hepatitis C antibody RPR (Syphilis) West Nile Virus Antibody Panel, ELISA LAB HBSAG HCV RPR WN Addendum B: Recommended Orders for Breast Milk Exposure Donor Mother
10 10 of 11 SARASOTA MEMORIAL HEALTH CARE SYSTEM 1700 S. Tamiami Trail Sarasota, FL Addendum C: Recommended Orders for Breast Milk Exposure Recipient Mother Weight kg Allergies: Food Allergies: Check box for STAT medications l! Date Time RECOMMENDED ORDERS FOR BREAST MILK EXPOSURE Recipient s Mother Labs: Rapid HIV if recipient mother is HIV negative OR HIV by Qualitative PCR if Recipient Mother is HIV positive Mnemonics R HIV HIV Q HTLV I & II antibody HbsAg (Hepatitis B Surface Antigen) Hepatitis C antibody RPR (Syphilis) West Nile Virus Antibody Panel, ELISA LAB HBSAG HCV RPR WN Addendum C: Recommended Orders for Breast Milk Exposure Recipient s Mother
11 11 of 11 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy. Committees/Sections/Departments: Date Director/Responsible Owner: Vice President/Executive Director: Chief of Medical Operations: (if clinical policy or appropriate) Chief of Staff: (if clinical policy or appropriate) Pam Beitlich, Director 5/14/18 Connie Anderson, CNO 05/22/18 James Fiorica, M.D., CMO 05/24/18 Medical Executive Committee: (if clinical and review requested by CMO and COS) Chief Executive Officer: David Verinder, CEO 05/25/18
SARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY
PS1013 SARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY TITLE: INTERPRETER SERVICES HEARING IMPAIRED/FOREIGN LANGUAGE EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: Job Title of Responsible Owner:
More informationSARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY
SARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY TITLE: LATEX ALLERGY POLICY #: EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: 5/28/97 08/25/17 Clinical 1 of 5 Non-Clinical Job Title of Responsible
More informationEast Carolina University Student Health Service
Page 1 of 5 Policy: BLOOD AND OTHER POTENTIALLY INFECTIOUS MATERIAL EXPOSURE POLICY FOR STUDENTS, WITH CLINICAL EXPOSURES s (SHS) will adapt and modify the policies and procedures of ECU Prospective Health
More informationBlood borne Pathogen Exposure Policy for Students
Blood borne Pathogen Exposure Policy for Students A University of Rhode Island (URI) student or intern who sustains an exposure from a needle stick, instrument stick, or mucous membranes to non-intact
More informationSUNY Downstate Medical Center -University Hospital of Brooklyn Network Department of Pathology Policy and Procedure
SUNY Downstate Medical Center -University Hospital of Brooklyn Network Department of Pathology Policy and Procedure Subject: NEWBORN SCREENING FOR METABOLIC DEFICIENCIES Prepared By: Yolaine Henry Edit
More informationCONTINUING CARE ADMINISTRATIVE MANUAL POLICY
CONTINUING CARE ADMINISTRATIVE MANUAL POLICY NUMBER III-10 DATE Draft June 8, 2010 PAGE 1 OF 3 APPROVED BY: SITE: CATEGORY TITLE: Vice President & Senior Operating Officer, Rehab & Continuing Care Edmonton
More informationPOLICY ON BLOOD AND BODY FLUID EXPOSURE (NEEDLE STICK)
POLICY ON BLOOD AND BODY FLUID EXPOSURE (NEEDLE STICK) Dated: January 1, 2018 Supersedes: Blood and Body Fluid Exposure (Needle stick) dated July 1, 2015 I. POLICY It is the policy of New York Medical
More informationBlood and Body Fluid Exposure
Blood and Body Fluid Exposure Infection Prevention and Control Contents Policy... 1 Purpose... 1 Scope/Audience... 1 Definitions... 2 Associated documents... 2 1.1 Indications for BBFE reporting... 2 1.2
More informationBreastfeeding Center Milk Connection Questionnaire and Release for Donor
Breastfeeding Center Milk Connection Questionnaire and Release for Donor All of us at The Breastfeeding Center are deeply grateful to you for your important gift to infants in our community. Your donated
More informationIRB Approved: 09-Jan-2015 To: 08-Jan-2016
Developing Assays to Evaluate Immunologic Response to HIV and HIV Vaccines CONSENT FORM/HIPAA AUTHORIZATION FOR VENIPUNCTURE Investigators: Pablo Tebas, MD Phone Number: (215) 349-8092 Study Staff: Joseph
More informationSt. Mary s Hospital Foundation Scholarship Program. Deadline: Must be postmarked by March 15, 2016
St. Mary s Hospital Foundation Scholarship Program Deadline: Must be postmarked by March 15, 2016 MedStar St. Mary s Hospital Human Resources Department 25500 Point Lookout Road Leonardtown, MD 20650 For
More informationSARASOTA MEMORIAL HOSPITAL DEPARTMENT POLICY
PS1006 SARASOTA MEMORIAL HOSPITAL DEPARTMENT POLICY TITLE: NON-INVASIVE VENTILATION FOR THE Job Title of Reviewer: EFFECTIVE DATE: REVISED DATE: Director, Respiratory Care Services 126.685 (neo) 3/26/15
More informationBloodborne Pathogen Exposure STUDENT. Blood Borne Pathogen Exposure. Student. Rev:
Blood Borne Pathogen Exposure Student INSTRUCTIONS 1. Student: Get name, DOB and, if available, health record number of source patient Obtain form and assist your supervisor with providing information
More informationAppendix 11 Roles and Responsibilities October, 2013 Page 1 of 5
October, 2013 Page 1 of 5 Exposed Person To present to a health care facility as soon as possible following the exposure (ideally within 2 hours). To answer assessment questions. (Refer to Appendix 15
More informationPrenatal Patients and Flu Vaccine Notes from the Field
Prenatal Patients and Flu Vaccine Notes from the Field 2010-2011 Elizabeth Rosenblum, MD 1, Sarah McBane, Pharm D 2, Wendy Wang, MPH 3, Mark Sawyer, MD 4 1 UCSD Dept of Family and Preventive Medicine,
More informationOB Provider Guide to Alaska s Perinatal Hepatitis B Prevention Program
OB Provider Guide to Alaska s Perinatal Hepatitis B Prevention Program Dear Colleague, This letter is to introduce myself and explain the role I play with the Alaska Perinatal Hepatitis B Program. Alaska
More informationFACULTY OF MEDICINE AND HEALTH SCIENCES SAFETY GUIDELINES FOR CLINICAL EDUCATION IN THE COMMUNITY
FACULTY OF MEDICINE AND HEALTH SCIENCES SAFETY GUIDELINES FOR CLINICAL EDUCATION IN THE COMMUNITY CONTENTS 1. GENERAL INFORMATION 2. SAFETY GUIDELINES 3. REPORTING OF AN INCIDENT 4. PROTOCOL FOR THE MANAGEMENT
More informationUsing Donor Human Milk in Extremely Premature Infants
Using Donor Human Milk in Extremely Premature Infants Introduction Scott Eaker, Vice President of Quality and Regulatory Affairs Scott Elster, Chief Executive Officer David Rechtman, MD, Chief Medical
More informationPAEDIATRIC PROVIDER INITIATED TESTING AND COUNSELLING
PAEDIATRIC PROVIDER INITIATED TESTING AND COUNSELLING This checklist is offered as an aid to support supervision and quality assurance for paediatric PITC services. Through observation, interviews and
More informationAn Effective Model to Communicate Complex Genetic Information to Families and Health Care Providers
An Effective Model to Communicate Complex Genetic Information to Families and Health Care Providers Theresa Steckel, RN, BSN Newborn Screening Quality Assurance and Education Coordinator Oklahoma State
More informationStructure and duties of Blood service
NATIONAL CENTER FOR TRANSFUSION MEDICINE Prevalence of infectious diseases among Mongolian blood donors Namjil Erdenebayar General director of The National Center for Transfusion Medicine, Mongolia NCTM,
More informationEl Paso - Ambulatory Clinic Policy and Procedure
Regulation Reference: Title: NEEDLESTICK INJURIES/EXPOSURES TO BODY FLUIDS, CARE & FOLLOW UP Policy Number: EP 7.3 Effective Date: 6/2010 Policy Statement: A system is established and maintained to assure
More informationUse of a Multidisciplinary Care Model for Pregnant Women Living with HIV & Their Infants Sarah McBeth, MD MPH
Use of a Multidisciplinary Care Model for Pregnant Women Living with HIV & Their Infants Sarah McBeth, MD MPH University of Pittsburgh Medical Center Disclosures Presenter has no financial interests to
More informationInformation to Make your Visit at the Clinic Smoother
Being ALIVE! Newsletter Winter 2012 Letter from Lisa McCall, Director The ALIVE Study has reached its 25th year! In the world of research, that s a very long time. And it s also a long time for participants
More informationSafety Regulations and Procedures Occupational Health Bloodborne Pathogens Exposure Control Plan S80.10, updated, May Contains information for:
APPENDIX A Safety Regulations and Procedures Occupational Health Bloodborne Pathogens Exposure Control Plan S80.10, updated, May 2018 BLOODBORNE PATHOGEN EXPOSURE INCIDENT PACKET Contains information for:
More informationin pregnancy Document Review History Version Review Date Reviewed By Approved By
GYNAECOLOGY/ ANTENATAL CARE WIRRAL WOMEN & CHILDREN S HOSPITAL Guideline No: Hepatitis B management in pregnancy VERSION 1 AMENDMENTS MADE: N/A DATE OF ISSUE: May 2012 DATE OF REVIEW: May 2015 REVIEW INTERVAL:
More informationRoutinizing HIV and HCV Testing Using an Innovative, Scalable and Sustainable Dual Testing Model
Routinizing HIV and HCV Testing Using an Innovative, Scalable and Sustainable Dual Testing Model Catelyn Coyle MPH, MEd Public Health National Symposium June 2014 Outline Background Description of model
More informationImproving Developmental
Improving Developmental Screening Practices for Young Children with Autism & Other Developmental Disorders A CME-certified course Tuesday, April 26, 2005 Lecture Hall Alfred I. dupont Hospital for Children
More informationAllergy/Intolerance Procedure
Subject/Title Approving Authority: Keith Dewar Allergy/Intolerance Procedure Classification: Patient Rights, Safety and Protection Contact for Interpretation: Documentation Coordinator - Clinical Quality
More informationINITIAL EVALUATION AND MANAGEMENT FOLLOWING EXPOSURE TO BLOOD OR BODY FLUIDS
Page 1 of 11 Original Date of Issue: June 1991 Reviewed 2/96 5/97 11/98 11/99 5/01 5/02 12/05 Revised 9/95 5/97 5/00 7/02 3/06 6/08 6/10 The following are the procedures to be followed when a person sustains
More informationNorthern Alberta preventing HIV transmission to babies
CATIE-News CATIE s bite-sized HIV and hepatitis C news bulletins. Northern Alberta preventing HIV transmission to babies 25 June 2009 Since 1996 the widespread availability of combination therapy for HIV
More informationBlood & Blood Product Administration
Approved by: Blood & Blood Product Administration Addendum to: Corporate Policy VII-B-397 Transfusion of Blood Components and Products- Pediatric/Neonate Gail Cameron Senior Director Operations, Maternal,
More informationCentral Franciscan Health Rensselaer Blood and Body Fluid Exposures Procedure COPY
Current Status: Active PolicyStat ID: 2625043 Original: 7/18/2011 Last Reviewed: 8/19/2016 Last Revised: 8/19/2016 Next Review: 8/19/2019 Responsible Party: Kristin Deno: Manager Policy Area: References:
More informationDear Applicant for Sober Living Environment Registration,
Dear Applicant for Sober Living Environment Registration, Thank you for your interest in Sober Living Registration. The California Consortium of Addiction Programs and Professionals, (CCAPP) endorses the
More informationBloodborne Pathogens. By Deborah Massarella RN, MSN
Bloodborne Pathogens By Deborah Massarella RN, MSN 2010, 2014 Objectives At conclusion of in-service learners will: 1. Identify two types of personal protective equipment. 2. Identify two prevention measures
More informationEXPOSURE (HIV/HEPATITIS) BLOOD & BODY FLUIDS
Page(s): 1 of 11 PURPOSE To set a standardized procedure to ensure that employees are evaluated in a consistent and timely manner.. POLICY A. The treatment of Team Member exposure to bloodborne pathogens
More informationTuesday, June 23, 2015
Tuesday, June 23, 2015 8:30 a.m. 3:30 p.m. Toftrees 1 Country Club Lane State College, PA 16803 Course Directors: Penny Chapman, MD Manish Sapra, MD, MMM James Schuster, MD, MBA Sponsored by The Center
More informationAPPLICATION FOR ADMISSION (PLEASE PRINT CLEARLY)
1317 w. Washington Blvd. Fort Wayne, In. 46802 260-424-2341 APPLICATION FOR ADMISSION (PLEASE PRINT CLEARLY) NAME: _ FIRST MI LAST DATE OF BIRTH: / / AGE: SOCIAL SECURITY NUMBER: LAST OR CURRENT ADDRESS:
More informationPolicy and Procedure for the Development, Approval and Implementation of Patient Group Directions in NHS Haringey Clinical Commissioning Group
BEFORE USING THIS POLICY ALWAYS ENSURE YOU ARE USING THE MOST UP TO DATE VERSION Policy and Procedure for the Development, Approval and Implementation of Patient Group Directions in NHS Haringey Clinical
More informationUNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM. A Pilot Study for Collection of Anti-Zika Immune Plasma
A Pilot Study for Collection of Anti-Zika Immune Plasma CONSENT TO PARTICIPATE IN A RESEARCH STUDY AND RESEARCH SUBJECT HIPAA AUTHORIZATION Your contacts for this study at the Hospital of the University
More informationSOP 17 BLOOD BANK. 3. Overall Responsibility: Blood Bank In-Change/Pathologist.
SOP 17 BLOOD BANK 1. Purpose: To ensure the availability of safe blood unit with facility for compatibility testing, storage and issue of blood in an aseptic environment on 24*7 basis trough trained professionals.
More informationA. Anti-HIV-1/2, HIV NAT Lookback: for those identified blood and blood components collected:
PURPOSE: MATERIALS: To outline a procedure for removing, recalling and/or correcting blood products that do not meet the requirements of the FDA, AABB, or the blood center. Recall/Market Withdrawal Form
More informationBlood Borne Pathogen Exposure Employee
Blood Borne Pathogen Exposure Employee INSTRUCTIONS 1. Employee: Get name, DOB and, if available, health record number of source patient Obtain form and assist your supervisor with providing information
More informationHepatitis B Positive: Care of Mother Policy
Document ID: MATY031 Version: 1.0 Facilitated by: Jo McMullan, CMM Last reviewed: October 2014 Approved by: Maternity Quality Committee Review date: October 2016 Hepatitis B Positive: Care of Mother Policy
More informationBrown-Lupton Health Service Texas Christian University Campus P.O. Box Fort Worth, TX Dear Student,
Brown-Lupton Health Service Texas Christian University Campus P.O. Box 297400 Fort Worth, TX 76129 817-257-7940 Dear Student, Enclosed you will find our policies, procedures and student consent form for
More informationInspections, Compliance, Enforcement, and Criminal Investigations. Central Texas Regional Blood & Tissue Center 07-Nov-03
1 of 7 6/10/2009 2:20 PM Inspections, Compliance, Enforcement, and Criminal Investigations Department of Health and Human Services Public Health Service Food and Drug Administration Dallas District 4040
More informationAIDS and insurance. Information about the necessity of AIDS testing Implications of undergoing an AIDS test The choices available to you INSURANCE
INSURANCE AIDS and insurance Information about the necessity of AIDS testing Implications of undergoing an AIDS test The choices available to you Please read carefully NSW and TAS only What is AIDS? AIDS
More informationSecond victim response: How to be first responders to second victims
Second victim response: How to be first responders to second victims Jenna Merandi, PharmD, MS Charline Catt, RN, MS Overview Define the term second victim Understand recovery stages of a second victim
More informationReporting from Council of Europe member states on the collection, testing and use of blood and blood components in Europe The 2006 Survey
Reporting from Council of Europe member states on the collection, testing and use of blood and blood components in Europe The 2006 Survey This questionnaire consists of three sections: A. Collection and
More informationIntegrating HIV Screening Into
MaxiMizing Third ParTy reimbursement for hiv TesTing Integrating HIV Screening Into Title X Services IntroductIon HIV screening services are a core family planning service, and all individuals aged 13-64
More informationFrozen Donor Embryo Transfer Price List, EDI 2017
Frozen Donor Embryo Transfer Price List, EDI 2017 Introduction: We have done our best to be accurate in estimating your fees. If you have had some of these tests completed relatively recently, they will
More informationHepatitis C Medications Hawaii PRIOR AUTHORIZATION REQUEST FORM
Please complete this entire form and fax it to: 866-940-7328. If you have questions, please call 800-310-6826. This form contains multiple pages. Please complete all pages to avoid a delay in our decision.
More informationUW MEDICINE REGIONAL HEART CENTER HEART TRANSPLANT. Orientation Class at University of Washington Medical Center
UW MEDICINE REGIONAL HEART CENTER HEART TRANSPLANT Orientation Class at University of Washington Medical Center OVERVIEW This slideshow explains: Your Transplant Evaluation Transplant Listing Heart Transplant
More informationTHE POWER OF UNDETECTABLE. What you need to know about HIV treatment as prevention
THE POWER OF UNDETECTABLE What you need to know about HIV treatment as prevention CONTENTS 3 Treatment as prevention First, a few basics: What is an undetectable viral load? How do I know if I m undetectable?
More informationHello! Again, thank you so much for your interest in becoming a Kentucky Adult Peer Support Specialist! Sincerely, David Riggsby
Hello! Thanks for your interest in Adult Peer Support Specialist Training! We are pleased to offer a curriculum that has been approved by the Kentucky Department for Behavioral Health, Developmental and
More informationPEDIATRIC EMERGENCY DEPARTMENT CLINICAL GUIDELINE: NON- OCCUPATIONAL EXPOSURE TO BLOOD-BORNE PATHOGENS (HIV, Hepatitis B, AND Hepatitis C)
General Definition: Blood-borne pathogens are infectious agents that can be transmitted through contact with blood or certain other body fluids. The primary pathogens are HIV, Hepatitis B, and C. Before
More informationInitiation of Clozapine Treatment Community Patients
Initiation of Clozapine Treatment Community Patients Who Should Read This Policy Target Audience All clinical staff working in the community N/A N/A Initiation of Clozapine Treatment for Patients in the
More informationTRANSFUSION ASSOCIATED DISEASE, RECALL, OR COMPLICATION INVESTIGATION POLICY I. FATALITIES AND COMPLICATIONS ASSOCIATED WITH TRANSFUSION:
I. FATALITIES AND COMPLICATIONS ASSOCIATED WITH TRANSFUSION: A. TRANSFUSION RELATED FATALITY: FDA and MEDIC must be notified immediately, and subsequently in writing, when a possible transfusion related
More informationUNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM
Gilead Sciences, Inc. GS-US-337-0115, 25-NOV-2013 A Phase 3, Multicenter, Open-Label Study to Investigate the Efficacy and Safety of Sofosbuvir/Ledipasvir Fixed-Dose Combination for 12 Weeks in Subjects
More informationAddress: City: State: ZIP code: Inferferon Product Requested (Include Strength):
Please complete this entire form and fax it to: 866-940-7328. If you have questions, please call 800-310-6826. This form contains multiple pages. Please complete all pages to avoid a delay in our decision.
More informationOB Well Baby Nursery Admission (Term) [ ] For specialty focused order sets for your patient, refer to: General
OB Well Baby Nursery Admission (Term) [3040000234] For specialty focused order sets for your patient, refer to: 3040000424 Neonatal Circumcision Order Set 3040000522 Neonatal Herpes Viral Order Set 3040000524
More informationEmergency Department Blood/Body Fluid Exposure Instructions
Emergency Department Blood/Body Fluid Exposure Instructions For employees sent to the Emergency Department after hours to be evaluated for needle stick / body fluid exposure 1. Floor or unit Charge RN
More information01.02 Blood Borne Pathogens (BBP) Occupational Post Exposure Management
01.02 Blood Borne Pathogens (BBP) Occupational Post Exposure Purpose Audience Policy Definitions Establish protocol for management of occupational exposures to blood or potentially infectious materials.
More informationCHAPTER Committee Substitute for Committee Substitute for House Bill No. 321
CHAPTER 2015-110 Committee Substitute for Committee Substitute for House Bill No. 321 An act relating to HIV testing; amending s. 381.004, F.S.; revising and providing definitions; specifying the notification
More informationSeasonal Influenza in Pregnancy and Puerperium Guideline (GL1086)
Seasonal Influenza in Pregnancy and Puerperium Guideline (GL1086) Approval Approval Group Job Title, Chair of Committee Date Maternity & Children s Services Clinical Governance Committee Chair, Maternity
More informationCORD BLOOD TRANSPLANTATION STUDY CBU EXCLUSION AND QUARANTINE RELEASE FORM
(Any answer of Yes indicates exclusion) 1. Informed Consent and Maternal/Infant Demographics a. Lack of confirmation of signed and witnessed informed consent 1 Yes 2 No Is the following information missing
More informationHEALTH SCREENING QUESTIONNAIRE. Work-up. Donor ID EdgeCell #:
HEALTH SCREENING QUESTIONNAIRE Héma-Québec Registre des Donneurs de Cellules Souches 4045 Côte-vertu, St-Laurent, QC, Canada, H4R 2W7 Tél : + 514-832-1031 Fax : + 514-832-0266 www.hema-quebec.qc.ca CT
More informationPATIENT GROUP DIRECTION PROCEDURE
PATIENT GROUP DIRECTION PROCEDURE Date approved 2 October 2015 Version 3 Approved by Yvette Oade, Chief Medical Officer Procedure Lead Clinical Governance Lead - Medicines Management Procedure Author Karen
More informationTitle: Fecal Occult Blood Test Number: TCFHT-MD01 Activation Date: Reviewed: Next Review:
MEDICAL DIRECTIVE Title: Fecal Occult Blood Test Number: TCFHT-MD01 Activation Date: 01-01-2014 Reviewed: 01-01-2015 Next Review: 01-01-2016 Sponsoring/Contact Person(s) (name, position, contact particulars):
More informationMaryland State Department of Education Maryland Department of Health and Mental Hygiene Maryland State School Health Council
Maryland State Department of Education Maryland Department of Health and Mental Hygiene Maryland State School Health Council MARYLAND STATE SCHOOL HEALTH SERVICES GUIDELINES Management of Students with
More informationWashington County-Johnson City Health Department Christen Minnick, MPH, Director 219 Princeton Road Johnson City, Tennessee Phone:
Washington County-Johnson City Health Department Christen Minnick, MPH, Director 219 Princeton Road Johnson City, Tennessee 37601 Phone: 423-975-2200 Dear Parent: The Washington County Health Department
More informationAdult Education. If you have any questions, please contact the Student Health Services office at (914) , extension 2243.
Adult Education IMPORTANT! You will NOT be allowed to register for classes without providing the health information requested in this packet. The information is mandatory as required by NY State Public
More informationHepatitis B Positive: Care of Mother Policy
Document ID: MATY031 Version: 1.0 Facilitated by: Jo McMullan, CMM Issue Date: July 2012 Approved by: Maternity Quality Committee Review date: October 2016 Hepatitis B Positive: Care of Mother Policy Purpose
More informationPolicy for the safe use of oral methotrexate
Policy for the safe use of oral methotrexate Policy Checklist Name of Policy: Purpose of Policy: Directorate responsible for Policy Name & Title of Author: Does this meet criteria of a Policy? Staff side
More informationA Decade of Data: Findings and Insights from the National Palliative Care Registry
A Decade of Data: Findings and Insights from the National Palliative Care Registry Maggie Rogers, MPH Senior Research Manager, CAPC Rachael Heitner, MA, CHPCA Research Associate, CAPC July 19, 2018 at
More informationCOMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE ASTHMA EAR INFECTIONS SORE THROAT BED WETTING HEADACHES UPSET STOMACH
COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE CHILD S CURRENT HEALTH STATUS DURING PREGNANCY DID YOU USE: DRUGS/MEDICATIONS TOBACCO/ALCOHOL IF YES, DESCRIBE YOUR DELIVERY: CHILD S HEALTH HISTORY INSTRUCTIONS:
More informationTitle: Fecal Occult Blood Test Number: TCFHT-MD01 Activation Date: 01-January-2014 Review Date: 08-October-2017 Next Review Date: 08-October-2018
MEDICAL DIRECTIVE Title: Fecal Occult Blood Test Number: TCFHT-MD01 Activation Date: 01-January-2014 Review Date: 08-October-2017 Next Review Date: 08-October-2018 Sponsoring/Contact Person(s) (name, position,
More informationMoms Help Organization Helping Moms to be the best Moms they can be! West Sample Road, #24 Coral Springs, FL
Moms Help Organization Helping Moms to be the best Moms they can be! 11471 West Sample Road, #24 Coral Springs, FL 33065 www.momshelp.org Application for Assistance Welcome to the Moms Help Organization.
More informationThe Twenty-First Annual Massachusetts Immunization Action Partnership. Pediatric Immunization Skills Building Conference
The Twenty-First Annual Massachusetts Immunization Action Partnership Pediatric Immunization Skills Building Conference October 27, 2016 9:00 am 4:00 pm Best Western Royal Plaza Hotel Marlborough, Massachusetts
More informationGuidance for Industry
Guidance for Industry Advisement for the Use of Gen-Probe Procleix Ultrio Plus Assay for NAT Testing on Cadaveric Donors Release Date: 08/03/14 American Medical Education and Research Association 4757
More informationWithin 14 days at 2-8⁰C. DO NOT FREEZE WHOLE BLOOD Micro Typing Systems 50 µl plasma
Test Name *Minimum Collection Tubes Sample Stability ABO/Rh Blood Typing 50 µl cells EDTA whole blood (lavender-top) Within 14 days at 2-8⁰C. DO NOT FREEZE WHOLE BLOOD Micro Typing Systems 50 µl plasma
More informationChris Kjolhede, MD, MPH Attending Pediatrician Bassett Healthcare Medical Center. Tdap for Dads
Chris Kjolhede, MD, MPH Attending Pediatrician Bassett Healthcare Medical Center I have no conflict of interest I have received no payment for this work/this presentation (though I do get lunch). 1 Pertussis/whooping
More informationWednesday, June 22, 2016
Wednesday, June 22, 2016 8:00 a.m. 4:00 p.m. Toftrees 1 Country Club Lane State College, PA 16803 Sponsored by the Center for Excellence in Rural Public Psychiatry, part of Western Psychiatric Institute
More informationAchieving Consensus on Increased Risk Donors to Improve Access to Organ Transplantation Executive Summary
Achieving Consensus on Increased Risk Donors to Improve Access to Organ Transplantation Executive Summary Introduction To address the current shortage of organs for transplantation, (114,651 candidates
More informationVERBAL CONSENT TO PARTICIPATE IN A RESEARCH STUDY AND HIPPA AUTHORIZATION
VERBAL CONSENT TO PARTICIPATE IN A RESEARCH STUDY AND HIPPA AUTHORIZATION Study Title: Cytokine Production and Lymphoproliferation With and Without Co-inhibitory Signaling Blockade: An Assessment of Functional
More informationCARE OF HEPATITIS B POSITIVE MOTHER
CARE OF HEPATITIS B POSITIVE MOTHER SCOPE All medical and midwifery staff employed by Hutt Valley DHB. All Hutt Valley DHB Maternity access holders. All Special Care Baby Unit staff PURPOSE The purpose
More informationTitle: Influenza Immunization Number: TCFHT-MD03 Activation Date: Review Date:
MEDICAL DIRECTIVE Influenza Immunization Number: TCFHT-MD03 Activation Date: 10-06-2014 Review Date: 15-09-2014 Sponsoring/Contact Person(s) (name, position, contact particulars): Shawn Goodman, RPh, PharmD
More informationAppendix C NEWBORN HEARING SCREENING PROJECT
Appendix C NEWBORN HEARING SCREENING PROJECT I. WEST VIRGINIA STATE LAW All newborns born in the State of West Virginia must be screened for hearing impairment as required in WV Code 16-22A and 16-1-7,
More informationUniversity of Pennsylvania RESEARCH Subject Informed Consent Form AND RESEARCH SUBJECT HIPAA AUTHORIZATION
University of Pennsylvania RESEARCH Subject Informed Consent Form AND RESEARCH SUBJECT HIPAA AUTHORIZATION Protocol Title: Evaluating the impact of cocaine use and HIV infection in arterial wall inflammation
More informationPandemic influenza Recommendations on the use of antiviral medicines for pregnant women, women who are breastfeeding and children under the age of
Pandemic influenza Recommendations on the use of antiviral medicines for pregnant women, women who are breastfeeding and children under the age of one year Updated September 29 DH INFORMATION READER BOX
More informationIRB Approval From: 3/8/2010 To: 10/28/2010
UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM Phase II Study to Assess the Safety and Immunogenicity of an Inactivated Swine-Origin H1N1 Influenza Vaccine in HIV-1 (Version 3.0, 16 FEB 2010) IRB Approval From:
More informationDear Parent or Guardian,
Dear Parent or Guardian, This summer may be a period of transition for you and your child. For a lot of our students it may even be the first time they are taking the lead in their personal care, including
More informationSARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY
PS1006 SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT TITLE: PROPOFOL SEDATION PROTOCOL Job Title of Reviewer: Director, ICU :#: EFFECTIVE DATE: REVISED DATE: TYPE: 1/95 8/06, 5/09 DEPARTMENTAL INTERDEPARTMENTAL
More informationA Natural Path toward health
Pediatric Intake Form (Newborn - 12 years) Welcome! It is my goal to provide your child with the best possible health care. In order to serve you optimally, please answer the following questions about
More informationBloodborne Pathogens Exposure Procedure
Bloodborne Pathogens Exposure Procedure Background: Bloodborne pathogens are infectious microorganisms present in blood that can cause disease in humans. These pathogens include, but are not limited to,
More informationDr. John C Rwegasha.FRCP(Lond),MSc, Muhimbili National Hospital Dar es Salaam Tanzania 15/09/2018 1
Dr. John C Rwegasha.FRCP(Lond),MSc, Muhimbili National Hospital Dar es Salaam Tanzania 15/09/2018 1 No disclosures. 15/09/2018 2 Sub-Saharan Africa (SSA) has a high burden of morbidity and mortality resulting
More informationVersion Number: 5. Patient Group Direction drawn up by: Chief Pharmacist - Strategy. Group direction authorised by:
PATIENT GROUP DIRECTION (PGD) FOR THE INPATIENT ADMINISTRATION OF ORAL LORAZEPAM TO WORKING AGE AND OLDER PEOPLE (includes persons in a Place of Safety suite) Version Number: 5 Patient Group Direction
More informationPolicy S- 15 FLORIDA STATE UNIVERSITY COLLEGE OF NURSING BLOODBORNE PATHOGEN EXPOSURE CONTROL PLAN FOR NURSING STUDENTS
TITLE: Policy S- 15 FLORIDA STATE UNIVERSITY COLLEGE OF NURSING BLOODBORNE PATHOGEN EXPOSURE CONTROL PLAN FOR NURSING STUDENTS Page 1 of 2 POLICY: The College of Nursing shall maintain a bloodborne pathogen
More information[Submitted Electronically]
[Submitted Electronically] Dr. Matthew J. Kuehnert, Director Office of Blood, Organ, and Other Tissue Safety Division of Healthcare Quality Promotion National Center for Emerging and Zoonotic Infectious
More informationEMPLOYEE HEALTH TABLE OF CONTENTS
EMPLOYEE HEALTH TABLE OF CONTENTS PHYSICAL ASSESSMENT.2 REPORTING EMPLOYEE INFECTIONS...3 SUMMARY OF IMPORTANT RECOMMENDATIONS AND WORK RESTRICTIONS FOR PERSONNEL WITH INFECTIOUS DISEASES.4 HEPATITIS B
More information