Hospital Transfusion Committee

and
Hospital Tissue Committee
m
  
m    


 !
 
ectives
‡ To e a le to create Hospital Transfusion Committee
(HTC)

‡ To define the role and terms of reference in HTC

‡ To know the mem ers of the HTC

‡ To know the activities of the HTC

‡ To know the meeting frequency of the HTC

 
 


‡ The Blood Matters program (initially BeST ± Better

Safer Transfusion program) and its advisory committee
aims to improve the outcomes in patients requiring
lood product transfusion y enhancing the safety and
appropriateness of lood and lood product use.
‡ The Blood Matters Program aims to:
± raise awareness and increase knowledge of transfusion
practice

± monitor and evaluate current practice against guidelines for

the prescri ing and administering of lood products

± record and analyse data a out incidents, including adverse

events and near misses, to inform policy and procedure
development.
 Blood Matter Program

‡ Transfusion governance

± part of the overall approach to clinical governance in a health

care organisation.

± Clinical governance is a vital leadership issue as an approach

of enhancing quality and safety in health care.

 Hospital Transfusion Committee

‡ To promote and provide the highest standard of quality care for

patients receiving lood/ lood components and lood products

‡ Will developed guidelines and policies, audit and using peer

review of transfusion practices.

‡ The HTC meet quarterly and the minutes/actions are recorded

accordingly.
‡ Mem ers
A. Institutional representatives such as:

‡ Clinicians: surgery, medicine, paediatrics, haematology,

oncology, orthopaedics, , anaesthesia, emergency,
ICU executive management clinical risk
management/quality assurance lood ank (scientist in
charge)nursing other relevant departments such as
pharmacy.
‡ External representatives such as:

± Philippine National Red Cross

± Blood Service Transfusion Medicine mem er

± Department of Health
 Scope and Duties
‡ Promote est practice y the use of national/local
guidelines.

‡ Regular review of the Hospital Blood Transfusion Policy

‡ Participate in oth national and local audit examining the

lood transfusion process against est practice.
þ. Have representative on the Regional Transfusion Committee and
receive updated information on the National Blood Transfusion
Committee that is disseminated to the HTC

5. There is continuous work with mem ers of the multi-disciplinary

team to further enhance est practice y the use of audit and
research ased practices

6. Promote the education and training of clinical la oratory and

support staff involved in lood transfusion.
K. Participate in the Blood Stocks Management Scheme to
minimize waste.

8. Manage change that promotes transfusion safety, continuously

reviewing practice that links with clinical governance.

9. Participate in the Serious Adverse Blood Reactions and Events

(SABRE) and Serious Hazards of Transfusion (SHT) reporting
system as well as the Trust Risk Management clinical incident
reporting.
( . Feed ack clinical incidents to oth the HTC and the specific
hospital staff involved. Action incidents accordingly to further
minimize risk.

((. Look at alternatives to transfusion and promote the work of the

HTC across the Trust.

(
. Continually strive to enhance and further develop est practice in

the field of Transfusion practice.
 Authority
‡ The Hospital Transfusion Committee is empowered to
examine and promote est practice within the
institution to the a ove scope and duties related to
transfusion.
 

‡ The Hospital Transfusion Committee receives reports from the
Hospital Transfusion Team and these are included in the HTC
meetings.

‡ The Deputy Nurse has representation on the group and feed ack
is given to oth the Deputy Nurse and Lead Nurses.

‡ The work of the HTC is feed ack to the Clinical overnance

Board.
 Èey Performance Indicator

‡ Staff attendance at the meetings will e monitored y the use of

registers.

‡ An Annual Summary report of achievements will e produced at

the end of each year and sent to the Clinical overnance Board.
 Hospital Transfusion Team (HTT)
‡ ive feed ack on the work of the group

‡ To manage the day to day usiness of Blood and Blood Component

Transfusion

‡ To reduce lood use and increase patient safety

‡ Meet once a month to discuss and work on issues around the

transfusion process
‡ Consists of the following:

± Clinical Nurse Specialist

± Transfusion La oratory Manager

± Transfusion Biomedical Scientist

± Consultant Hematologist

(
 
ective

‡ Assist implementing the actions of the HTC in

promoting the highest standard of quality of care for
patients receiving lood/ lood components and lood
products.
 Frequency and Attendees of the
Meeting

‡ There may e invited a Hospital Board and Hospital employee¶s

to the meeting if their input is required regarding specific
pro
ects and agenda issues.

‡ Meetings shall e held every
months to HTC

 Scope and Duties
‡ Assist in the implementation of the Hospital Transfusion
Committee¶s o
ectives.

‡ Promote and provide advice and support to clinical teams on the

appropriate and safe use of lood.

‡ Actively promote the implementation of good transfusion practice.

‡ Act as a resource for training hospital staff involved in the process

of lood transfusion.
‡ Produce an annual report including achievements, action plan for
transfusion safety, quality and lood conservation and resource
requirements for consideration y senior management at Board
level through the HTC.

‡ Assist in Trust compliance with the Blood Safety and Quality

Regulations and future laws and guidelines relating to lood
transfusion.

‡ Implement an action plan for compliance with National Patient

Safety Agency initiatives.
 Reporting

‡ The Hospital Transfusion Team reports directly to oth

Hospital Transfusion Committee¶s within the Trust.

‡ Minutes of meetings and the actions taken will e

su mitted to the HTC.
 Agenda Coverage
‡ Minor errors

‡ Ma
or errors and Clinical incidents

‡ Reports to Serious Hazards of Transfusion (SHT) and

Serious Adverse Blood Related Events (SABRE) at the
Medicines and Healthcare Regulatory Authority (MHRA)

‡ Blood stocks management including wastage

‡ Blood stocks management including wastage

‡ Budgetary issues

‡ Protocol and Standard perating Procedures (SP)

changes

‡ Ma
or Accidents
‡ Training and Education

‡ Audit

‡ Autologous Transfusion

‡ Factor VIIa usage

 ther

‡ ffer advise and assistance on alternative to lood transfusion

‡ Plans for patients who refuse lood transfusion

 Terms of References

‡ To promote est practice in transfusion medicine

‡ To monitor usage of lood and components within the

hospital review
 Blood Services
‡ Blood Donation
± Attracts and retains donors through regular advertising and
marketing campaigns
‡ Donors and Blood Donations
‡ Testing
± AB group
± Rh group
± 5 transmissi le infectious diseases
 Transfusion Facts
‡ Blood Types

‡ Compati ility Testing

 Blood Products
‡ Fresh Whole Blood
‡ PRBC
‡ FFP
‡ Cryoprecipitate
‡ Platelet
 Blood Management
‡ Patient lood management
± Encompasses a holistic approach to the use of lood products for
each individual patient; using the premise of µwhy transfuse¶
rather then µwhy not¶.

± Carefully alance enefits and potential harm.

± Belief that lood and its components are iological products, the
effects of which are not fully understood, and have the potential
for unwanted consequences.
± Aim of µ etter treatment outcomes¶ for the patient.

± To maximize haemoglo in (preoperatively, intra-operatively

and post-operatively); minimise lood loss (including lood
taking) and to use alternatives to lood transfusion where these
are availa le and feasi le.
 


‡ Patients have a choice a out whether or not to undergo a
proposed procedure or treatment, including transfusion
of lood and lood products.
‡ Purpose:
± Provide enough information a out the transfusion
care they may receive
± promoted and facilitated y WH.
‡ Important points
± Valid and informed consent process is conducted and
documented.
± Emergency procedures will e undertaken in compliance
with the uardianship and §
 §
  

± Appropriate su stitute consent will e taken when

patients cannot consent for themselves.

± Treating medical practitioner is responsi le for o taining

consent.

± In the case of a Jehovah¶s Witness or any other refusal of

treatment, in either adults or children
‡ Important points to cover when o taining informed
consent:
± Explain
± Ask
± Provide
± Document

‡ Consumer information on consent for transfusion

 Clinical Audit
‡ Aims:
± Identify areas for practice improvement; develop and carry out
action plans to rectify or improve care; and then re-audit to
ensure that these changes have the desired effect.

± Compare current transfusion practices with clinical est

practice guidelines.

± If any areas for improvement are identified, practices are

examined and modified where necessary.
 Tips for Auditing

‡ Collect only the essential data

‡ Maintain and ensure patient confidentiality

‡ Have clear o
ectives and aims

‡ Identify stakeholders that may e affected y your audit and

involve them in discussion
 Tips for Auditing

‡ If required employ a team of people

‡ Analyse and compare your audit against standards or guidelines

‡ Make recommendations and develop a plan to implement those

recommendations
‡ Analyse and compare your audit against standards or guidelines

‡ Make recommendations and develop a plan to implement those

recommendations

‡ Re-audit, once recommendations are in place, to assess

improvements

‡ Talk to your quality/clinical governance department, as they may

have already conducted audits similar to those you are
considering.
 Haemovigilance
‡ Risk management and haemovigilance
± Set of surveillance procedures covering the whole transfusion chain (from

the collection of lood and its components to the follow-up of

recipients)

± intended to collect and assess information on unexpected or

undesira le effects resulting from the therapeutic use of la ile
lood products to prevent their occurrence or recurrence
‡ The Blood Matters¶ Serious Transfusion Incidents
Reporting (STIR) system

± Is a central reporting system for serious adverse

events involving the transfusion of fresh lood or
lood products including near-miss incidents.

± STIR currently collects data on the following

serious incidents:
‡ Acute transfusion reaction (ATR)

‡ Delayed transfusion reaction (DTR)

‡ Transfusion-related acute lung in
ury (TRALI)

‡ Bacterial/other infection

‡ Transfusion-associated graft versus host disease (TA-VHD)

‡ Post-transfusion purpura (PTP)

‡ Post-transfusion viral infection

‡ Incorrect lood component transfused (IBCT)

‡ Wrong lood in tu e (WBIT)

‡ Near miss
 National Blood Authority (NBA) ±
National Haemovigilance Pro
ect

‡ It will report on serious transfusion-related adverse events

relating to fresh components occurring in pu lic and
private hospitals.
‡ Improve transfusion safety and quality y collecting,
analyzing, and disseminating information on a common
set of adverse events surrounding the transfusion of lood
products.
‡ The report provides limited data on the types of adverse
transfusion events that have een reported in some
healthcare reporting systems over the past three to five
years.

‡ It will also e used to assist development of a

framework for the future Australian haemovigilance
program.
 National Blood Supply Contingency
Plan (NBSCP)

‡ It is a document that outlines the risk-management

approach taken to assessing the possi le pro lems,
governance arrangements and the road overarching
strategies in place to mitigate a supply or demand crisis.
‡ Aims to improve awareness and ensure appropriate
planning is in place for dealing with the impact of a
lood crisis in the health sector.

‡ This document is supported y a range of response

annexes to guide key stakeholders in responding to a
supply or demand crisis.
‡ The overarching response involves three levels of
accounta ility:
± National: covers the roles of national government odies such
as the NBA and the TA, in gathering and communicating
information etween governments and suppliers and is the link
to roader government emergency management arrangements.
‡ perational: covers the role of suppliers in managing
required operational activities around collection,
manufacture, distri ution and interface with the clinical
community.

‡ Clinical: covers the role of clinicians and pathology

providers in good communication, managing clinical
demand, and approaches to triage to ensure access to
products for patients with greatest and most urgent
clinical needs.
 Classification system availa le to support
clinicians and institutions with their decisions.

‡ Blood Access Priority (

± Resuscitation
± Surgical support
± Non-surgical anaemia

‡ Blood Access Priority

± Surgery and o stetrics
± Non-surgical anaemia
‡ Blood Access Priority 3
± Surgery
‡ Elective surgery requiring cross-matched red lood
cell support of two or more units of homologous
donor lood
± Non-surgical anaemia
± ther non-urgent medical indications for transfusion
± Notes for all priority levels
‡ All priority levels must consider the following:
± Alternatives to transfusion (For example:
erythropoietin, iron therapy, red cell salvage).
± A reduction in target post-transfusion haemoglo in.
HOSPITAL TISSUE
COMMITTEE
 Background
‡ Hospital Tissue Committee reviews the appropriateness of all
surgical procedures performed in the institution, correlating pre-
and post-operative surgical diagnoses with pathological findings

‡ A review of the surgery performed in a hospital or other health

care facility. The evaluation is usually made on the asis of the
extent of agreement of the preoperative, postoperative, and
pathologic diagnoses and on the relevance and accepta ility of
the diagnostic procedures.
 Mem ers
‡ Chief of Hospital
‡ Pathologist- Ex fficio
‡ Representative from Dept. of Surgery
‡ Representative from Dept of B-yne
‡ Representative from Dept. of phthalmology
‡ Representative from Hospital Administration
‡ Representative from Nursing Department
‡ Representative from La oratory Department-
Histopathology Section
 
ectives

‡ To study and report to the staff, or to the Executive

Committee of the staff, on the agreement or
disagreement among the preoperative, postoperative and
pathological diagnoses and on whether the surgical
procedures undertaken in the hospital were
ustified or
not.
 Purpose
‡ To study statistics in the Pathology La oratory Includes the
num er of su mitted tissues, num er of apparently missed
diagnoses, percentages of normal tissues removed and num er of
deaths.

‡ To discuss all cases in which there is inconsistency Includes

clinical, operative and pathologic diagnosis, investigation of all
cases in which normal tissues were removed and discussion of such
cases.
 Purpose

‡ To discuss and study of all deaths.

‡ To discuss and correct the su -standard practice of a certain

resident physician


 

 Review of patient medical history, pathological reports and operative
record
Vital information of the patient

Review of the patients chart

Committee Appraisal

Cases presenting inconsistencies or potential deficiencies in desired

standards of care

Refer to administrative medical staff committee

accumulating an excessive quantity of cases (sub-standard px care)
requiring executive committee examination

Retrieval of committee records

cetermine the specific pattern of corrections.

 Statistical Report

‡ The Tissue Committee reviewed ( operations

performed in this hospital during the month of July
‡ Inconsistency of the surgical operation
‡ Investigate
‡ Correction
‡ Executive Committee for disposition