A member inquired about compliance with JCAHO Standard: PI.3.1.1 "The organization collects data to monitor the performance of processes that involve risks or may result in sentinel events." At the inquiring member's hospital center they have embarked on some very labor-intensive audits. These audits were based in part on the 1997 article by Shulman and Jones in the American Journal of Clinical Pathology. The inquiring member's current transfusion practice audit involves following a unit from the time it is issued from the blood bank to the finish of transfusion. A resident in pathology is assigned the task of monitoring and documenting each step in the process. The hospital has done about 100 such audits in 2 years time. Although the number of audits per month is only 4 to 5, it still requires a lot of effort per audit. Although the inquiring member's transfusion service has identified problems based on these audits, they would like to change the way they comply with the AABB standard. The inquiring member would like to know what others are doing to comply with the standard; what types of audits are being done and are there any audits or monitors that are successful in meeting the intent of the standard?

The following responses have been submitted for discussion:

1. A very wise blood banker in Tennessee wrote that direct observation of the actual transfusion event (including pickup, delivery, setup and identification of the recipient) is not required by AABB Standards and never has been required. However, there is considerable data that indicate direct observation of the transfusion is a very good way of identifying problems, including very important problems such as not looking at the recipient's wrist band. In fact, in the responding member's opinion, it is the best way. Of course, some other department could perform direct observation, but in this person's experience this isn't likely to happen unless stimulated by the transfusion service. To make a change, the facility's quality plan would have to be altered, and the new program instituted. How else can one be sure that the procedure of administering blood is being performed correctly, and that the written procedure itself is adequate and being followed? A retrospective study can't yield the information obtained by direct observation. The inquiring facility uses residents to perform this audit. This is an excellent method of collecting this data. They should be congratulated, particularly since they are finding variances. Using the audit as a teaching tool makes it an even more valuable activity. It may also result in more frequent in-service training of nursing personnel in the technique of blood/component administration.

2. A second, equally wise blood banker from California, stated that AABB Standard 8.2 does not specifically require direct observation of blood administration practice, but does imply that the process of transfusion be monitored in some way. The Standard states: " 8.2 Monitoring of Blood Utilization All transfusing facilities shall have a peer review program that monitors transfusion practices for all categories of blood and components. The following shall be monitored:

1. Ordering practices.
2. Sample collection.
3. Usage (including discard of components).
4. Appropriateness of use.
5. Blood administration policies.
6. The ability of services to meet patient needs.
7. Compliance with peer review recommendations.

How audits occur and how many are performed is up to each facility. If this facility has identified problems in this process, then they may be advised to continue to monitor the process and to take corrective action as needed. If they have identified problems on only one aspect of this process, such as the identification of the patient at the bed side, then they could elect to target their audits to this area, and determine what corrective action could be taken to resolve the issues. If the problems have not been resolved, and problems continue to occur, they may need to increase the audits to get a better idea where the root causes are, and find a corrective action plan that will correct the problems. All of these choices can be made by the facility, and should be made with the safety of the patient and the preservation of the blood product in mind, not just the number of audits that are performed and the time spent doing them. The purpose of the audits are to identify problem areas, the responsibility of the facility is to analyze the results of the audits and take actions as needed to correct any problems. The facility can also tailor their audits to achieve the goals of being assured that the blood administration process is running without any problems.

3. EDITOR's NOTE: At both the LAC+USC Medical Center and at the USC Kenneth Norris Cancer Hospital, the assessment of blood administration practices is done by direct observation. We have found this to be a very useful and important monitoring tool, and we are convinced that the monitoring has improved the level of practice and the degree of compliance with established hospital policy and procedure. This assessment process, however, needs to be done on a continual basis, otherwise the gains in improved practice seem to fade away. For more information, see:

• Shulman IA et al. Monitoring transfusionist practices. Transfusion, 1994
• Shulman IA et al. Practical aspects of self-assessment and administration of blood. Am J Clin Path 1997
• Shulman IA et al. Assessing blood administration practices. Arch Path Lab Med., 1999
• Whitsett C & Robichaux M. Assessment of blood administration procedures. Transfusion, May 2001

(For another aspect of this issue, visit the earlier discussion on this forum.)

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator