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Mabel Adams

Decoding AABB Std 8.2 on Blood Utilization Monitoring

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In your program to monitor Blood Utilization according to AABB std 8.2, how do you define and what do you do for "Ordering Practices", "Appropriateness of Use", "Blood Administration Policies", "Ability of services to meet patient needs" and "Compliance with peer-review recommendations"? Some of these seem to overlap or are vague. For instance, how is "Ordering practices" different from "Appropriateness of use"?

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At my hospital, we split out our Blood Utilization monitoring like this (below) to cover each of these 10 AABB requirements:

1. Ordering Practices: C/T Ratios (Total and by Service), Uncrossmatched Blood Requests, Compliance with MD signature completion on "Release of Uncrossmatched Blood" forms

2. Patient Identification: Any Patient ID issues identified are reported

3. Sample Collection and Labeling: BBK Specimen acceptability report (outliers are detailed)

4. Infectious and Noninfectious Adverse Events, Incidence of Mistransfusion: Transfusion Reactions, Recalls, Notifications

5. Near-Miss Events: Anything identified would be detailed along with root-cause, corrective action

6. Usage and Discard: Units transfused, Units discarded

7. Appropriateness of Use (for all Components):

QA Audits performed by Medical Director, report pulls 100% products transfused (one type of product per month) and the most recent related lab data to when the product was issued. Outliers are investigated by the Medical Director. MDs receive follow-up letters on questionable transfusions.

Jan/Apr/Jul/Oct = RBC compared to most recent Hgb/Hct

Feb/May/Aug/Nov = PLT compared to most recent PLT count

Mar/Jun/Sep/Dec = FFP and CRYO compared to most recent PT/PTT and Fibrinogen

We also review any Autologous transfusions, Peri-Op Collection/Reinfusion (Cell Saver, Hemodilution, ECMO) and Therapeutic Apheresis and Phlebotomies performed during the quarter.

8. Blood Administration Policies and Practices: Our QA department performs random audits on 75 transfusions per quarter (coordinated with the RBC, PLT, and FFP/CRYO schedule above) and audits for MD Order to Transfuse, Issue Checks Performed, Bedside Checks Performed, Vitals Recorded. Since we are using TAR, all transfusion data is now entered into the computer so this audit can be done using computer reports. We also audit 100% of all transfusions for "Duration Less than 4 Hours" by running a computer report. We also report on Bedside Blood Administration Audits which are performed by the blood bank techs (minimum of 16 per year) and Blood Warmer QC which is performed quarterly by Biomed.

9. Ability of Services to Meet Patient Needs: We do Turnaround Time studies (Type & Screen, DAT, Crossmatch, Newborn Workup), report on any Customer Complaints and Cancelled Treatments. We also have a Bloodless Medicine and Surgery program so we report on the number of patients enrolled in the program who were treated without transfusion.

10. Compliance with Peer Review Recommendations: Letters Written/Sent to Phsyicians from the Medical Director and/or Blood Utilization Committee Chair, and Responses Received

I know, some of these do overlap somewhat, but "Ordering Practices" would be looking at how many and what kinds of products are doctors routinely ordering for various things (i.e. are they over-ordering or under-ordering for certain types of surgeries/procedures, do they order uncrossmatched too often because lack of ordering in advance) and "Appropriateness of Use" would be looking at whether they make the decision to actually transfuse those ordered products to their patients based on appropriate criteria (lab results, patient symptoms, etc.).

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What do you consider customer complaints? Only patient or doctor complaints or all "write-ups"?

Also, do you have a clear definition of a "near miss" or is it just based on your judgment?

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What do you consider customer complaints? Only patient or doctor complaints or all "write-ups"?

Also, do you have a clear definition of a "near miss" or is it just based on your judgment?

A customer complaint could be from anyone: doctor, nurse, nursing staff, or patient/family. They can come as email, phone call or through the hospital QA system. We also track the complaints we occasionally have with our blood supplier (delays, product shortages, mislabeled historical Ag negative units, etc). Those get reported back to the blood supplier in a report each quarter.

Near misses are pretty much a judgement call on my part. I always consider... if someone would not have caught and corrected this mistake, would it have negatively impacted the safety of a patient? If the answer is Yes, I consider it to be a near miss. On our lab variance form, we have a grading key with these definitions:

Grade (severity)

0 = No Grade level required: Not Applicable

1 = No clinical harm or injury to patient/staff. (Inconvenience, delay, patient redraw, customer dissatisfaction)

2 = Potential for or actual mild harm/cost. (Self-limited, recovery complete, little to no discomfort, unnecessary expense)

3 = Potential for (near miss) or actual moderate harm. (Definitive treatment required, prolonged hospital stay)

4 = Potential for (near miss) or actual severe harm. (Life-threatening, permanently disabling, death)

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