On our last CAP, Inspector sighted the bllood bank because surgerys, procedure did not state what they did for QA, we have been quarlerly getting a samole for culture and HCT. Would be intersected in how other handle this. I have just taken over as blood bank supervisor.

I am assuming your are referring to:

TRM.41550 Phase II N/A YES NO

Do the procedures for intraoperative and perioperative blood recovery provide adequate protection for the patient?

COMMENTARY:

A protocol and appropriate safeguards for intraoperative and perioperative blood recovery are necessary to prevent transfusion accidents.

REFERENCE: Yawn DH. Ensuring quality during intraoperative blood salvage. Lab Med. 1994;25:626-631.

You should have a defined quality assurance policy that includes Medical Director participation in writing and reviewing policies and procedures for the program. In addition you should have defined policies for quality control. It appears you are doing quality control. Other items needed for quality assurance include employee competency assessments, assessment of the program, employee training, quality control records, and defined policies and procedures. The procedures used for the program should comply with AABB standards (i.e., filters, etc). Once written you must be able to produce these records.

If you or your facility is AABB accredited you can view their site for these requirements (Assessment Tools) or purchase this material from the book store.

Hope this helps.

MWLister

Thanks. We are working with surgery to develope the policy and procedure which before our inspection surgery could not find there policy. The inspector wasn't happy because the new policy that was being written did not include any thing about quality control and had not been reviewed by the Laboratory

Director.

I'm wondering if quarterly QC sufficient? Shouldn't each unit reinfused have some QC?

Victoria T.