Monitoring transfusionist practices: a strategy for improving transfusion safety

Transfusion. 1994 Jan;34(1):11-5. doi: 10.1046/j.1537-2995.1994.34194098595.x.


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.

Study design and 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.

Conclusion: 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.

MeSH terms

  • Blood Transfusion, Autologous / standards*
  • Compliance
  • Humans
  • Medical Audit
  • Medication Errors / statistics & numerical data*
  • Pilot Projects
  • Quality of Health Care