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Monitoring transfusionist practices: a strategy for improving transfusion safety
Author(s) -
Shulman I.A.,
Lohr K,
Derdiarian AK,
Picukaric JM
Publication year - 1994
Publication title -
transfusion
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.045
H-Index - 132
eISSN - 1537-2995
pISSN - 0041-1132
DOI - 10.1046/j.1537-2995.1994.34194098595.x
Subject(s) - phlebotomy , medicine , abo blood group system , blood component , transfusion medicine , blood transfusion , administration (probate law) , intensive care medicine , emergency medicine , surgery , political science , law
BACKGROUND: Data from New York State indicate that about 1 of every 33,000 red cell units transfused is ABO‐incompatible with the recipient. National application of these data suggests that as many as 360 ABO‐incompatible whole blood and red cell transfusions might occur annually in the United States. Phlebotomy and blood bank laboratory errors cause some of these ABO‐incompatible transfusions, but the greatest number result either partially or solely from the failure of transfusionists to identify properly either a patient or the blood component a patient receives. STUDY DESIGN AND METHODS: A quality assessment/quality improvement (QA/QI), process is described that allowed for the direct oversight (monitoring) of transfusionists' practices and for the assessment of institutional policies for blood administration. RESULTS: At the beginning of the QA/QI process, monitoring of blood administration practices revealed that a variance from institutional blood administration policy occurred during 50 percent of blood and component transfusions. As a result of the QA/QI process, the percentage of transfusions with an associated variance from institutional policy dropped to nearly zero. CONCLUSION: The QA/QI process described in this report, or one similar to it, could improve transfusion safety and serve as a model for increased involvement by transfusion service medical directors in the oversight of transfusionists' practices.