The Transfusion Medicine Team - A Hospital Perspective

Abstract

Background and aim Three serious transfusion-related incidents over a 9 month period highlighted the clinical risk in transfusion during 2001–2002. This lead to the development of a strategy to comprehensively review and implement transfusion safety initiatives across the Bayside health network of which the Alfred is a major hospital. Intervention The initiative commenced in January 2003 with the assembly of a multi-disciplinary team that consisted of medical, nursing, scientific as well as hospital executive representation. This was possible with the appointment of a Transfusion Nurse as part of the Victorian Department of Human Services Blood Matters Collaborative and a Transfusion Medicine Registrar, co-appointed by the hospital and Australian Red Cross Blood Service. The activities consisted initially of process mapping blood transfusion practice. Key areas were then selected for targeting process improvement, namely; – Patient and product identification, – Sample labelling, – Blood component administration. Result Initiatives implemented were; – Widespread medical and nursing education on transfusion issues. – Increase transfusion information availability. – Network-wide implementation of strict criteria for specimen labelling (all specimens) in line with ANZSBT pre-transfusion testing guidelines. – Development of a pre-transfusion testing and blood request form. – Development of a blood administration form to reconcile all transfusion related documentation in the medical record. - Policy and guideline development. Conclusion Sustained improvement requires ongoing dedicated personnel to maintain gains, continue to audit practice, analyse incident data both actual adverse incidents as well as near-miss events and to respond to these challenges within an ongoing and operational quality improvement framework.