Monitoring transfusionist practices: a strategy for improving transfusion safety.
BACKGROUND
Data from New York State indicate that about 1 of every 33,000 red cell units transfused is ABO-incompatible with the recipient. National application of these data suggests that as many as 360 ABO-incompatible whole blood and red cell transfusions might occur annually in the United States. Phlebotomy and blood bank laboratory errors cause some of these ABO-incompatible transfusions, but the greatest number result either partially or solely from the failure of transfusionists to identify properly either a patient or the blood component a patient receives.


METHODS
A quality assessment/quality improvement (QA/QI), process is described that allowed for the direct oversight (monitoring) of transfusionists' practices and for the assessment of institutional policies for blood administration.


RESULTS
At the beginning of the QA/QI process, monitoring of blood administration practices revealed that a variance from institutional blood administration policy occurred during 50 percent of blood and component transfusions. As a result of the QA/QI process, the percentage of transfusions with an associated variance from institutional policy dropped to nearly zero.


CONCLUSIONS
The QA/QI process described in this report, or one similar to it, could improve transfusion safety and serve as a model for increased involvement by transfusion service medical directors in the oversight of transfusionists' practices.
Shulman
I A
IA
Los Angeles County-University of Southern California Medical Center.
Lohr
K
K
Derdiarian
A K
AK
Picukaric
J M
JM
D001804:Blood Transfusion, Autologous / Q000592:standards*; D003187:Compliance; D006801:Humans; D008485:Medical Audit; D008508:Medication Errors / Q000706:statistics & numerical data*; D010865:Pilot Projects; D011787:Quality of Health Care