Blood Transfusion Review Committee



Attachment 5 HPM 113-02JAMES A. HALEY VETERANS HOSPITAL HOSPITAL POLICYTAMPA, FLORIDA 33612 MEMORANDUM NO. 113-02 SEPTEMBER 2009BLOOD TRANSFUSION REVIEW COMMITTEE1. PURPOSE: To establish and define policies, membership and responsibilities related to the Blood Transfusion Review Committee. 2. POLICY: This Committee is established according to the standards of The Joint Commission (TJC) and the American Association of Blood Banks (AABB). The Blood Transfusion Review Committee will oversee development and monitor compliance with all policies and procedures related to ordering, distribution, handling, grouping, typing, cross-matching, storing, transporting, dispensing, administering, and monitoring effects of blood, blood components, and blood derivatives transfused to patients. The Committee will also oversee development and monitor compliance with policies and procedures related to therapeutic phlebotomy, autologous blood donation, and therapeutic apheresis. The Blood Transfusion Committee review and evaluate the professional practices at this facility related to the appropriateness of blood, blood component, and blood derivative transfusion therapy in order to reduce patient morbidity and mortality and improve the quality of health care services while minimizing wastage and unnecessary usage of these valuable resources. 3. DELEGATION OF AUTHORITY AND RESPONSIBILITY: a. The Director is responsible for policy approval and distribution. b. The Chief of Staff is responsible for policy implementation and appointment of the Chairperson. c. Appropriate Service Chiefs are responsible for appointing representatives to the Committee and responding to information requests and corrective actions requested by the Committee. Service Chiefs are also responsible for developing performance measures for providers in their area who transfuse blood, blood components, and blood derivatives and using data supplied by the Committee in pursuit of this activity. d. The chairperson is responsible for calling the meeting to order, running the meeting, assuring that the Committee fulfills its designated purpose by completing necessary actions and following established policies, standards, and procedures, and assuring that minutes and memos are generated, reviewed, and distributed. e. The membership is responsible for attending meetings; participating in discussions; contributing to recommendations; developing, updating, and reviewing policies related to blood transfusion therapy; aiding the chairperson when requested; and communicating to their Service items of interest or importance. f. The resource person is responsible for aiding the chairperson with generation and distribution of minutes, memos and communication with Committee members. g. The Chief of Pathology & Laboratory Medicine or designee is responsible for reporting a summary report of the Committee’s activities to the Clinical Executive Board (CEB) on a quarterly basis. h. The CEB is responsible for overseeing Committee activities.4. PROCEDURES: a. The Committee will meet monthly (excluding holidays) or at the call of the Chair. The minutes will be maintained and distributed by the Pathology & Lab Medicine Service. An agenda will be available at the start of each scheduled meeting. A summary report of the Committee’s activities will be reported to the Clinical Executive Board (CEB) by the Chief of Pathology & Laboratory Medicine or designee on a quarterly basis. b. The Committee will develop, review, and update/revise hospital policies related to blood transfusion therapy, therapeutic phlebotomy, therapeutic apheresis, and autologous blood donation. These reviews/updates will occur at least every three years and currently include the following policies. (1) HPM 113-3, Transfusion Committee Audit Standards for the Use of Blood, Blood Products, and Blood Derivatives (2) HPM 113-4, Policy for Autologous Donation and Transfusion (3) HPM 113-6, Policy for Therapeutic Apheresis Procedure (4) HPM 113-7, Policy for Reporting Adverse Reactions to Blood or Blood Components (5) HPM 113-12, Informed Consent for Blood and Blood Product Transfusion (6) HPM 113-14, Preoperative Orders for Type and Screen & Type and Crossmatch (7) HPM 113-15, Policy for Therapeutic Phlebotomy c. The Committee will monitor compliance with the above noted policies. All aspects of transfusion, including proper documentation of informed consent for transfusion, transfusion administration, and performance of the Blood Bank will be monitored. Any complaints, problems or issues brought to the attention of the Committee by the medical staff, other committees or hospital employees related to these policies will be reviewed and evaluated by the Committee. Action plans and/or corrective actions will be initiated and implemented by the Committee. d. The Committee, following the guidelines established in HPM 113-3, will review the transfusion practices of the medical staff. (1) The Committee will use these audit standards to retrospectively monitor (screen) the appropriateness of at least 10% of RBC, 100% of platelet, 100% of FFP, 100% of cryoprecipitate, 100% of CMV negative RBCs and platelets, 100% of irradiated RBCs and platelets, 100% of any special request blood components (excluding leukocyte reduced RBCs and platelets), and 100% of blood derivative transfusions on a monthly basis. (2) Monthly, Florida Blood Services (FBS) will supply the Chairperson of the Committee with data on all blood and blood components issued. This data will include the number and type of products, full patient name and SS#, physician name, and date of transfusion. (3) The chairperson or designee will review all cases of transfusion that do not comply with these standards, secondary to insufficient information, improper/incomplete documentation, or potential inappropriate usage. Information examined for the initial review will include FBS Blood Bank records, laboratory test results, and the patient’s electronic medical record. (4) If further review is felt to be necessary by the chairperson, the case will be referred to the Committee for review at its next monthly meeting. (5) Cases referred to the Committee will be subjected to an intensive assessment. The patient's medical record will be closely examined and the Service Chief of the patient’s attending physician will receive a memo from the Committee requesting justification for the transfusion and/or use of the specific blood product or derivative. It is the responsibility of the appropriate Service Chief to either respond to this memo or have the patient’s attending physician respond to the Committee. By responding, the attending physician has an opportunity to present any additional information that influenced their decision to transfuse the patient or clarify the reason that a specific product was used. (6) After completion of the intensive assessment and review of all appropriate records, the case will undergo a final review by the Committee at the next meeting. Based on the information available, the Committee will render a decision regarding the appropriateness of the transfusion. (7) If the case was deemed inappropriate or inadequately justified, the Service Chief of the patient’s attending physician will receive a memo from the Committee stating this decision. The Transfusion Committee minutes will document the findings and decisions on all cases reviewed by the Committee. (8) The Committee will maintain a list of all providers who have been cited for inappropriate or inadequately justified transfusions. Monthly, a list of providers cited within the last fiscal year will be supplied to the Chiefs of Medicine and Surgery and any other appropriate Service Chiefs. (9) The names of physicians who are repeatedly cited for inappropriate or inadequately justified transfusions will be referred to the Chief of their Service and a copy of this notice will also be sent to the Chief of Staff or designee for any additional corrective actions deemed necessary. The Committee reserves the right to refer cases to the Risk Management Committee, if deemed necessary. (10) If a provider disagrees with the findings and recommendations of the Committee, they are advised that they may address the Committee in person or in writing or via their service’s representative. (11) Additional information presented by the provider may result in a reversal of the Committee’s original findings and recommendations. If such a reversal of findings occurs, the provider’s Service Chief will be notified and the change noted in the Committee minutes. Providers have the ability to appeal to the Clinical Executive Board (CEB). e. The Committee will review all cases with suspected transfusion reactions characterized by hemolysis, severe allergic or anaphylactic manifestations, circulatory overload, or infection. They will review all Incident Reports related to adverse blood reactions, suggest any additional corrective actions, and guarantee that all corrective actions are completed to their satisfaction. f. All case discussions and documentation of Committee actions are considered confidential and privileged under 38 U.S.C. 5705, and records/documents, which identify patients, licensed independent practitioners, or other health care providers, are protected.5. REFERENCES: Comprehensive Accreditation Manual for Hospitals: The Official Handbook. The Joint Commission, Current edition.7. FOLLOW-UP RESPONSIBILITY: Chairman of the Blood Transfusion Review Committee under Pathology & Lab Service (113) is responsible for updating this hospital policy memorandum. 7. RESCISSION: Hospital Policy Memorandum No. 113-2, dated September 2006.Stephen M. LucasDirectorDistribution: Electronic Distribution to All EmployeesJAMES A. HALEY VETERANS HOSPITAL HOSPITAL POLICYTAMPA, FLORIDA 33612 MEMORANDUM NO. 113-02 ATTACHMENT A SEPTEMBER 2009BLOOD TRANSFUSION REVIEW Committee MembershipMedical Staff, Pathology & Lab Medicine ServiceChairpersonMedical Staff representative, Anesthesiology ServiceMemberMedical Staff representative, Medicine ServiceMemberMedical Staff representative, Hematology SectionMemberMedical Staff representative(s), Surgery ServiceMemberPhysician representative, Florida Blood Services (FBS)MemberRepresentative, Nursing ServiceMemberRepresentative, Pharmacy ServiceMemberRepresentative, Quality ManagementMemberTechnical representative, Florida Blood Services (FBS)MemberSecretary, Pathology & Lab Medicine ServiceResource ................
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