I am trying to come up with some new things for QA for this coming year and wondered if anyone had any ideas? Currently we monitor all of our mislabeled specimens, our TAT on stat and ER specimens, our crossmatch to transfusion ratio, etc. We've tried monitoring transfusion tags to make sure they were properly filled out by nursing but when we were getting less than 50% nursing decided they would monitor that themselves and now it is miraclously 95-100%, imagine that! I am most interested in adding things we the techs can improve on ourselves for now, that way I know I will get compliance! Can anyone share what different things you monitor? Thanks!

I monitors everythig you monitor. I also monitor Specimen/blood component request slip:

1)I look for completeness---Diagnosis, physician name, typenex number, rationale for ordering blood component, test ordered(I find some without any test checked off)

2) > 4 hr transfusion

3) Transfusion records

4) Blood product outdates

5) blood product wastage

6) Transfusion reactions

Let me know if anyone else have any other suggestions.

We have electronic charting so we can monitor whether or not the completed record of transfusion gets to the patient's chart. We had a programmer write a program which matches component charges to the number of transfusion tags that are on the charts.

It was surprising how many were missing.

Since this has been an issue on inspections by our State Board of Health, if we find that tags are missing, we send the Blood Bank copy to Health Information for electronic scanning to the chart.

You may want to think of items that improve your current processes. For example, we monitored units out of the bank too long, FFP outdating (we shouldn't have any as we changed to thawed plasma), labeling errors on blood products, computer entry errors. We did audits which could lead to a long term monitor. Some audits we did: were techs following our solid organ crossmatch policy, our conditional release policy, were we getting variances for issuing low yield platelets. Find areas where you are perceiving problems and see if there is a problem. Look for areas where you think there are no problems, you may be surprised. We were with one of our audits that lead to a monitor being put into place until the problem was resolved.

Here is a list of things I monitor. This may not be of use to you if you do not have a donor center as well as a transfusion service, but you may see something you like:

INTERNAL AUDITS

Viral Marker Deferral Record Audit

# Records Reviewed (total positive viral marker tests)

# Discrepancies / Error Rate

Donor Deferrals (Total and Percentage of 'Donors Seen')

Deferrals for Low HCT (Total and Percentage of 'Donors Seen')

Allogeneic and Directed Donor Blood Collected - Total

Fixed Site Allos

Directed

Neonatal CPDA-1, O neg

Mobile

Therapeutic Exchanges / Therapeutic Phlebotomies

LSDP Collections / Total SDP Including Double Collections

Products Not Meeting QC Monitor Specifications

LRBC Residual WBC QC Failures (residual WBC>5x10e6)

LSDP Residual WBC QC Failures (residual WBC>5x10e6)

LSDP pH QC Failures ( pH<6.3)

LSDP-- Prequalification Platelet Count Failures (<3x10e11)

LSDP-- Intended Double Failures

LSDP-- QNS at Collection

LSDP-- Positive Culture / Confirmed Negative

Unusable Products - Donor Services - Total

QNS Whole Blood Collection

Clotted units- collection 10 minutes or less

Clotted Units- collection more than 10 minutes

Air Contamination and Unusable Overdraws (Phlebotomy)

Air Contamination and Wasted RBCs (Component Processing)

Donor Card Errors Resulting in Loss of Unit

Adverse Events/Complaints Received

Class "A" FDA Reportable Errors & Accidents

Class "B" Non-Reportable or Pt/Donor Safety Errors

Wasted Products - Transfusion Services and Nursing

Total Number by Service

RBC + LRBC + WRBC

FFP

CRYO

Apheresis LSDP Products

WB/AWB

Aliquots / Exchange Products for Neonates

Improperly Labeled Samples (mislabeled, incomplete)

Specimen Problems (hemolyzed, QNS, hemodiluted)

Proficiency Testing:

CAP J: Transfusion Medicine (Jan /A, Jun /B, Sep /C)

CAP DAT (Feb, Nov)

CAP HBF ( May, Nov)

CAP ABT (Jun /A, Oct /B)

CAP ELU (Mar, Jul)

Hct: Jan, Apr, Jul, Oct (25 samples/event)

Transfusion Related Cell Count (Jan, May, Aug)

Products Received from Other Centers - Total

LRBC

SDP

Cryo

FFP

Transfusion Services STAT T&S TAT (% within 1hr/Total # )

% within 1 hr 15 mins / % within 1 hour 30 mins

QA Review with Staff

BC

So Bob, what do you do in your spare time?

As a passenger train locomotive engineer (35 years), I run excursion passenger trains, usually about 4 times a month. Running trains is my relaxation.

http://www.austinsteamtrain.org

BC

BOb, How many assistant do you have? Or may be you have very nice computer program which can collect all the data you need directly from your LIS system!!!

WE do not collect so most of your list doesn't apply to us but you gave us a very good list of monitors one can use.

I am glad I could help.

I am a one-person QA department in the donor center. I do a lot of administrative queries in the two modules (donor and transfusion services). I review 100% of all work done. Most of what I review is in the computer, but we also have a lot of cGMP forms that I review. To prevent calculation errors, I have created calculating spreadsheets so that the processing techs just enter the test results (platelet counts, for instance) and the spreadsheet says PASS or FAIL. All I have to do is make sure they have entered the correct test results, weight of the unit, etc. I couldn't do what I do without the review tools I have created.

BC

We monitor product wastage and expense,improper storage,phlebotomy TAT, recollects,>4 hour infusion times,Transfusion Slip completeness,logs for refrigerators in surgery and cardiac ICU, blood usage in surgery, C/T ratio, and then anything else each year where we perceive there may be a problem.

To monitor the >4 hour infusion times, do you just go to the patients' charts to see the start and stop time?

In additions to the QC items listed we monitor "blood products not immediately available" as we are a small hosptial.

In additions to the QC items listed we monitor "blood products not immediately available" as we are a small hosptial.

I think I made a big mistake and erased the quote by aakupaku.

I am sorry

Is there a way to retireve the quote?