According to a blood banker in Georgia, his institution REQUIRES that two licensed individuals, one of whom MUST be an RN, sign off on the transfusion record form before a component transfusion begins. The Georgian has reviewed the AABB Standards, the CAP Transfusion Medicine Inspection Checklist and the JCAHO accreditation standards, and realizes that these documents are vague (or permissive) in this subject area. The inquiring blood banker requests feedback from e-network colleagues about what others require in terms of the personnel who are allowed to hang blood and/or sign off the transfusion record.

Editor's note: It seems that if one were to actually require (as the Georgian reports is the case at his institution) that only 'licensed' individuals can hang or sign off the transfusion record, then the following individuals would not be allowed to hang blood medical students, interns (before they get their medical license), student nurses, certified perfusionists, and perhaps other personnel categories; such a limitation is probably problematic as discussed in a previous issue on this forum. A reasonable approach is to require that transfusing personnel are adequately trained so as to be competent in the procedure.

In response to the above query, the following replies were submitted.

1. According to a transfusion medicine physician in Sacramento, regarding the number of persons required to sign off on the transfusion record, in his community, two people are supposed to check everything prior to a transfusion, but only one need be a "licensed" person, defined as a doctor (not specified whether an intern or not), a nurse (either RN or LVN), or other, e.g., CLS.

ADDENDA Nov. 7, 2007

2. A colleague in Irvine, California reports that her hospital’s blood administration policy requires that two licensed persons perform the clerical check of the intended recipient and the unit of blood prior to initiating a blood transfusion. She wonders if such a policy is required by municipal, state, or federal law or by accreditation requirements of AABB or CAP. If not required by law or accreditation, she asks if one licensed person and one unlicensed person can perform this check?

3. A California colleague who is very familiar with California regulations reports that based on his review of AABB Standards, FDA requirements, California Health and Safety Codes, and current CLIA guidelines that he is unaware of a requirement that licensed personnel must perform the clerical check. He cautions that each institution should review their own policies, including who may authorize and administer blood or blood components (scope of practice issues for license categories), and review AABB section 5.19.4 of the AABB Standards for BBTS which references the "transfusionist". Since administration of blood components is a scope of practice issue, the responsibility of the licensed personnel should include verification of the "medication" being issued.

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