Ttrm.30550

[Virginia]

It's clear that some blood banks are too large to permit the occasional transfer of information between technologists and nurses. We consider this interdisciplinary dialogue to be of real value in providing safe transfusions.

Also repeat types do have value. In a perfect world technologists would never be distracted from their work. However in smaller labs techs must answer phone calls, issue blood, and deal with suppliers, shipments, emergencies, etc... Handling all the details that make a transfusion service run involves a lot of interruptions, and it is not impossible to imagine a mistype due to loss of attention. Retypes are cheap insurance.

I believe that CAP's new TRM.30550 reflects their espousal of some of the key principles of W. Edw. Deming, widely respected as the father of the Quality revolution. Some of those are:

1. Cease dependence on mass inspection to achieve quality. Instead, improve the process and build quality into it.

2. Break down barriers between departments. People must work as a team to foresee problems.

3. Eliminate exhortations and targets asking for zero defects. They only create adversarial relationships, as the bulk of the causes of low quality belong to the system and thus lie beyond the power of the work force.

In other words, people are only human, and the best trained and intentioned individual can still make a mistake if the system is not designed to prevent it. We shall continue the search for an answer to TRM.30550, perhaps it will be the "Blood Lock" described by James AuBuchon in TRANSFUSION, Vol 46, No 7.

[sarahk]

Deming was, of course, talking about quality in a manufacturing environment. Whether or not those principles (and six sigma and TPS and kan ban, etc.) are transferable to health care is debatable. Certainly, they cannot be applied exactly as is--they need some tweaking. Quality in an environment like health care cannot be reduced to 14 points. To be truly effective, quality needs to start and be championed by those in the highest levels of an organization. Including one question in a specific department checklist isn't the way to achieve buy-in by hospital administration, especially when the benefits of such a requirement are unproven at best. And because this is truly a multi-disciplinary issue, is it appropriate to address it in only a laboratory inspection? Wouldn't an initiative by Joint Commission be a better way?

The reality is that the problem of mistransfusion is primarily a nursing issue. The lab doesn't hang blood. In fact, many laboratories (along with their nursing services) have excellent systems and processes in place to prevent mistransfusion. With this question, CAP says that those systems are not good enough no matter how well they've worked. Makes you wonder who owns stock in the bedside barcoding companies...

[jhoannac]

how do you suggest we comply with this checklist question?

[rhall51]

I'm wondering how to comply with a couple of sections of this item. I am using a log sheet to document errors and actions taken regarding sample identification from collection. But how can we address "the transfusion itself including recipient identification"?

TRM.30550 Misidentification Risk

The facility has a documented program to ensure that the risk of pretransfusion sample misidentification and other causes of mistransfusion are monitored and subjected to continual process improvement.

NOTE: The laboratory must actively monitor the key elements of the transfusion process, including, as applicable, donor management, unit production and handling, sample identification and testing, and the transfusion itself including recipient identification.

Evidence of Compliance:

Occurrence records/error logs documenting appropriate review and follow-up of significant errors in identification and other processes AND

Records of investigation and appropriate corrective/preventive action (e.g. education of staff, changes in procedures, etc.) for significant errors/review of monitoring data for corrective action and process improvement, when appropriate