The Joint Commission Reported Transfusion-Related Sentinel Events

Posted on January 17, 2012 by Susann Nienhaus, RN, JD

Last fall The Joint Commission (TJC) published sentinel event data from 2004 through the first 3 quarters of 2011.1  While TJC cautions that this data is not epidemiologically meaningful because the events are for the most part voluntarily self-reported and represent only a small portion of actual events, TJC encourages us to recognize that information from these reports and resulting root cause analyses are an important source of information for “lessons learned” that can help prevent similar adverse events from occurring. During the first 3 quarters of last year, TJC reviewed 14 transfusion-related sentinel events taking the total to 92 investigated “hemolytic transfusion reactions involving administration of blood or blood products having major blood group incompatibilities” since 2004. What lessons are these events teaching us?  Continue reading →

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To predonate or not to predonate, that is the question

Posted on November 15, 2011 by Timothy Hannon, MD, MBA
To predonate or not to predonate, that is the question

© Strategic Healthcare Group LLC

Last’s week’s Journal of the American Medical Association included a clinical crossroads case study on autologous predonation (1). The scenario was a relatively healthy, non-anemic woman (“Mrs. C”) who was scheduled for elective knee replacement surgery and was asking for advice on blood avoidance options.  Her specific concerns were voiced as: “Personally, I do not want anyone else’s blood. I believe I should give my own blood for safety reasons. I read the paper a lot and watch the news, and you hear so much about infectious diseases. That’s my concern; I have never had an infectious disease in my life and at this age, I don’t think I want to get one.”(1)  From her standpoint, she logically inquired about options such as predonating her own blood prior to surgery or using a directed donor. Continue reading →

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Iron: It’s Not Just for Hemoglobin

Posted on September 9, 2011 by Irwin Gross, MD

Iron deficiency is common – very common. Estimates of the prevalence of iron deficiency in the U.S. vary depending on the age of the population studied and co-morbidities. In the National Health and Nutrition Examination Survey (NHANES III) iron deficiency was present in 1-2% of adults (1). Continue reading →

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Untangling transfusion, patient safety, and biologic product deviations

Posted on August 4, 2011 by Carolyn Burns, MD

by Dr. Carolyn Burns, Medical Director, Transfusion Services, Strategic Healthcare Group LLC

The July supplement to Transfusion, the Journal of Blood Services Management, contains an excellent and quite provocative article surrounding the knowledge of the Food and Drug Administration (FDA) reportable deviations.  [1]

For those outside the highly regulated world of the blood donor center or hospital transfusion service, the FDA biologic product deviations (BPDs) are likely unfamiliar.  Continue reading →

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Nursing: The Art and Science of Safe Transfusion

Posted on May 10, 2011 by Amelia Baffa, RN
Nurses at the heart of transfusion safety

© Strategic Healthcare Group LLC

In honor of National Nurses Week Strategic Healthcare Group would like to recognize nursing’s vital role in blood management and transfusion safety.   Continue reading →

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Are YOU a Blood Donor?

Posted on April 11, 2011 by Carolyn Burns, MD

Click to enlarge

After receiving my third phone call in two days from my transfusion service personnel with concerns about our inventory, I realized yet again how important the role of stewardship is to our blood supply. Inventory issues seem more glaringly apparent during inclement weather or holiday seasons, however stewardship should be a continuous and daily activity. Continue reading →

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Guiding Transfusion Guidelines: Part 2

Posted on March 14, 2011 by Timothy Hannon, MD, MBA
Transfusion Orderset

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Last month’s article on Guiding Transfusion Guidelines: Part 1 covered the general concepts of implementing clinical practice guidelines. Appropriate transfusion decisions are a critically important and often overlooked part of the transfusion safety chain from donor to patient1, so evidence-based transfusion guidelines are a necessary piece of blood utilization infrastructure. Perhaps the biggest problem hospitals face is to actually assign hard and fast numbers for transfusion criteria, often referred to as “transfusion triggers,” for specific blood products. In general, physicians don’t like being told what to do (the issue of autonomy) because of the years of training and experience required to practice medicine. Continue reading →

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Guiding Transfusion Guidelines: Part 1

Posted on February 14, 2011 by Timothy Hannon, MD, MBA

Transfusion OrdersetFebruary is my favorite month to discuss improving blood utilization because it is the anniversary of the Transfusion Requirements in Critical Care (TRICC) trial, published in the New England Journal of Medicine on February 11th, 1999.1 In this landmark study2, 838 anemic critically ill patients were prospectively randomized into one of two treatment strategies:  transfuse at a hemoglobin level of 10 gm/dL, a very traditional approach to these challenging patients, or transfuse at a hemoglobin level of 7 gm/dL, which was a significant departure from common practice in 1999.  Continue reading →

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Blood Administration from The Joint Commission Perspective

Posted on January 10, 2011 by Susann Nienhaus, RN, JD

The Joint Commission (TJC) has been evaluating and accrediting hospital laboratory services since 1979 and freestanding laboratories since 1995. Today, approximately 3,000 clinical laboratories have earned TJC accreditation and the Gold Seal of Approval™. In compliance with CLIA regulations, Joint Commission standards address processes from laboratory specimen collection through analysis to result reporting. The Joint Commission’s stated objectives of the laboratory survey include evaluation, education and “‘good practice’ guidance that will help staff continually improve the laboratory’s performance.” Continue reading →

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Improving Blood Transfusion Consent

Posted on December 13, 2010 by Susann Nienhaus, RN, JD
Doctor and patient discussing informed consent

© Strategic Healthcare Group LLC

Some time ago my delightful 80+ year-old grandmother was diagnosed with a GI bleed that led to hospitalization and multiple transfusions. As I am the only nurse in the family, she made a point to tell me that she needed blood because her “hemoglobins were low.” I quickly determined that she had no idea what hemoglobin was but she was confident her transfusion therapy was necessary because her trusted family physician had told her that her “hemoglobins were low.” Continue reading →

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