MONITORING TRANSFUSIONIST PRACTICES - A STRATEGY FOR

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-i ncompatible whole blood and red cell transfusions might occur annually in the United States. Phlebotomy and blood bank laboratory errors cau se some of these ABO-incompatible transfusions, but the greatest numbe r result either partially or solely from the failure of transfusionist s to Identify properly either a patient or the blood component a patie nt receives. Study Design and Methods: A quality assessment/quality im provement (QA/QI) process is described that allowed for the direct ove rsight (monitoring) Of transfusionists' practices and for the assessme nt of institutional policies for blood administration. Results: At the beginning of the QA/QI process, monitoring of blood administration pr actices revealed that a variance from institutional blood administrati on policy occurred during 50 percent of blood and component transfusio ns. As a result of the QA/QI process, the percentage of transfusions w ith an associated variance from institutional policy dropped to nearly zero. Conclusion: The QA/QI process described in this report, or one similar to it, could improve transfusion safety and serve as a model f or increased involvement by transfusion service medical directors in t he oversight of transfusionists' practices.