Jump to content
Quality_Lady

Blood Utilization - Peer Review

Recommended Posts

Has anyone come up with a way to comply with the "peer review" in AABB Standard 8.2 (Transfusing facilities shall have a peer-review program that monitors and addresses transfusion practices for all categories of blood and blood components.) other than presenting data at Transfusion Committee Meetings?

Share this post


Link to post
Share on other sites

We are looking at sending the transfusions outside of threshold to the chiefs of each specialty to review. However we do not know yet how we can confirm they are reviewing it. Currently we send them quarterly CT ratios.

Share this post


Link to post
Share on other sites

We have a Transfusion Safety Officer as part of our Blood Utilization/Management program. They are responsible for monitoring and addressing utilization, wastage and training of all staff involved blood transfusions. Any Safety Event reports that are related to blood or blood components are automatically routed to her (we have an electronic reporting system). There is a weekly meeting of the Transfusion Safety Officer, Blood Utilization Manager and Blood Utilization Medical Director to review outliers and Safety Events and if necessary letters are sent to physicians where there may have been straying from the transfusion guidelines. The utilization team is also setting up a new endeavor to make a dashboard on the hospital intranet blood usage and wastage available to all clinical staff showing usage/wastage by medical department i.e. surgery, heme/onc, obstetrics etc. That way they can see info for themselves and how their department as a whole is doing.

Share this post


Link to post
Share on other sites
On ‎10‎/‎31‎/‎2018 at 6:43 AM, jalomahe said:

We have a Transfusion Safety Officer as part of our Blood Utilization/Management program. They are responsible for monitoring and addressing utilization, wastage and training of all staff involved blood transfusions. Any Safety Event reports that are related to blood or blood components are automatically routed to her (we have an electronic reporting system). There is a weekly meeting of the Transfusion Safety Officer, Blood Utilization Manager and Blood Utilization Medical Director to review outliers and Safety Events and if necessary letters are sent to physicians where there may have been straying from the transfusion guidelines. The utilization team is also setting up a new endeavor to make a dashboard on the hospital intranet blood usage and wastage available to all clinical staff showing usage/wastage by medical department i.e. surgery, heme/onc, obstetrics etc. That way they can see info for themselves and how their department as a whole is doing.

Sounds like an amazing program - Congrats to your team!

Share this post


Link to post
Share on other sites
On 10/31/2018 at 4:43 AM, jalomahe said:

We have a Transfusion Safety Officer as part of our Blood Utilization/Management program. They are responsible for monitoring and addressing utilization, wastage and training of all staff involved blood transfusions. Any Safety Event reports that are related to blood or blood components are automatically routed to her (we have an electronic reporting system). There is a weekly meeting of the Transfusion Safety Officer, Blood Utilization Manager and Blood Utilization Medical Director to review outliers and Safety Events and if necessary letters are sent to physicians where there may have been straying from the transfusion guidelines. The utilization team is also setting up a new endeavor to make a dashboard on the hospital intranet blood usage and wastage available to all clinical staff showing usage/wastage by medical department i.e. surgery, heme/onc, obstetrics etc. That way they can see info for themselves and how their department as a whole is doing.

I'm just curious but are any of these people, Transfusion Safety Officer, Blood Utilization Manager and Blood Utilization Medical Director, part of the Transfusion Service with a blood bank background?  If not, what is the Transfusion Service's involvement in the process?  :coffeecup:

Share this post


Link to post
Share on other sites
On ‎11‎/‎4‎/‎2018 at 9:09 AM, John C. Staley said:

I'm just curious but are any of these people, Transfusion Safety Officer, Blood Utilization Manager and Blood Utilization Medical Director, part of the Transfusion Service with a blood bank background?  If not, what is the Transfusion Service's involvement in the process?  :coffeecup:

The people you mentioned are RNs and MD (Heme/Onc specialty) and do not have a Transfusion Service background although the are very good at asking questions of the Transfusion Service. They are currently working on getting AABB Certification for the Blood Management program so they have LOTS of questions.

The Transfusion Service Medical Director, Supervisor and the Lead Technologist are all part of the Blood Management Committee. All policies and procedures that involve ordering, handling, and transfusion of blood/blood components are reviewed by the Transfusion Service. We also give input and review RN and MD training materials. We provide statistical information and are also involved in recommending/reviewing/testing of updates/upgrades for the HIS (Epic) which utilizes BPAM for transfusion documentation. And of course we attend all of the Blood Management meetings and they attend all of our Transfusion Service meetings so everyone stays on the same page.

All in all it is a great collaboration between our 2 groups. We just had our CAP inspection in September and our inspector was very complimentary with our program.

Share this post


Link to post
Share on other sites

We are a small hospital of @300 beds. I do all the auditing, statistics, writing of policies and procedures, etc. as well as being on the bench most of the time. There is no way I will ever "catch up" to where I would like to be under these circumstances. I say all that to let you know how lucky you are to have all of those people being part of the Transfusion Services to take care of those aspects of the job.

We have a quarterly meeting that includes 2-3 RNs that cover safety, compliance, and monitoring of the hospital, not just us. Also my lab director and assistant, Pathologist, one MD from the birthing center (even though any of them are welcome). This Blood Utlization meeting seems to satisy the AABB as they have never questioned in depth. My problem is  the RN who is in charge of the meetings and takes my statistics to review random cases. I know she is spread thin but when I question any RN or physician practices in transfusion, she ALWAYS sides with the RN or physician with no proof only that she is convinced it was correct. It shouldn't be like that. I'm not trying to get people in trouble, I just feel that the process should be a collaborative process, not an "us against them" process and the way she handles it I feel contributes to the environment of an internal conflict.

Just sayin'!

Share this post


Link to post
Share on other sites
On 10/31/2018 at 6:43 AM, jalomahe said:

We have a Transfusion Safety Officer

If you consider sharing a job description, it would be appreciated.  You can either post it here for all to see, or PM me if you'd prefer it not to be public.

Share this post


Link to post
Share on other sites
On ‎11‎/‎9‎/‎2018 at 6:34 PM, Cliff said:

If you consider sharing a job description, it would be appreciated.  You can either post it here for all to see, or PM me if you'd prefer it not to be public. 

Here's a easy read version of the Transfusion Safety Officer job description at our facility. Hope it gives you an idea of what might be possible at other facilities.

TSO JOB DESCRIP.doc

Share this post


Link to post
Share on other sites

I have seen facilities that attach the peer review to the Trauma Committee (if you have one) or the P&T (pharmaceuticals and therapeutics) committee, which I think every hospital has in some form or another.

Share this post


Link to post
Share on other sites
23 hours ago, jalomahe said:

Here's a easy read version of the Transfusion Safety Officer job description at our facility. Hope it gives you an idea of what might be possible at other facilities.

TSO JOB DESCRIP.doc

Thank you

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Advertisement

×
×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.