Content

Objectives

Reading Assignment

Introduction

• Discuss how hospital administrators at all levels set the tone for transfusion safety.
• List functions of the hospital transfusion committee that help ensure patient transfusion safety.

Pages 290-310

Scope of Hospital Transfusion Practice

• Discuss how the hospital transfusion medicine service contributes to patient transfusion safety.

Lessons from Hemovigilance Programs

• List frequent causes of errors leading to mistransfusion.
• List factors that may be responsible for undertransfusion.
• Discuss potential adverse outcomes associated with poor management of blood stocks.
• Identify what is increasingly recognized as the most frequent serious adverse event caused by overtransfusion.

Hospital Transfusion Committees (HTC)

• Discuss which personnel should be included in hospital transfusion committee membership.

Patient Roles and Informed Consent

• Describe the process for informed consent for a blood transfusion to ensure patient understanding.  

Administration of Blood and Blood Components and Management of the Transfused Patient

• Discuss adverse effects of transfusion prescription errors.

• Identify which transfusion records should be kept as permanent clinical records. 

Technologies to Reduce Patient Misidentification Errors in Administering Blood

• List the information included in a pretransfusion identity check between the patient and a blood component.

Guidelines, Algorithms and Protocols

• Identify examples of guideline recommendations embedded into the materials used during decision-making and administration processes to help improve compliance with a hospital's transfusion practice policies.

Clinical Audit and Feedback

• Discuss factors that influence the effectiveness of audits and feedback.
• List the disadvantages of using retrospective transfusion audits as a strategy to improve clinical practice.
• List the forms that audits, performed concurrently with blood component ordering but before product issue, can take.

Public and Political Perceptions and Fear of Litigation 

• State the measures implemented in the United Kingdom in the late 1990s in response to concerns about the potential for transfusion-transmitted variant Creutzfeldt-Jacob disease (vCJD).

Local Investigation and Feedback Following Near Misses and Serious Adverse Events

• Define “near miss” as related to transfusion medicine.
• Identify typical weaknesses often identified through systematic root cause analyses of “near misses” or serious adverse events.
• Discuss appropriate corrective actions for “near miss” or serious adverse events.

Centralization of Transfusion Services

• Identify the most important patient safety benefit of a centralized transfusion service.