HOW DO I . . .? How do we utilize a transfusion safety officer? Nancy M. Dunbar1,2 and Zbigniew M. Szczepiorkowski1,2
The hospital transfusion safety officer (TSO) serves an important role in improving transfusion safety outside of the laboratory through education, active surveillance of the transfusion process (patient identification, blood administration, appropriate ordering practices, transfusion reactions, incidents, and near misses), patient blood management (blood utilization review, minimization of perioperative blood loss, documentation review), quality improvement (transfusion guidelines development, transfusion committee or peer review participation, massive transfusion protocols), and research. We provide a description of how we utilize our hospital-based TSO to improve transfusion safety and ensure compliance with regulatory requirements and maintenance of certification at our institution.
T
he modern transfusion safety officer (TSO) evolved from “blood bank nurse coordinator” or “transfusion service liaison” positions that have been in existence in some hospitals since the 1960s.1 The first documented transfusion safety position in the United Stated was at the University of Washington Medical Center in 1962.2 By the year 2000, the modern equivalent of the TSO was well established in France and the United Kingdom and the launch of a successful regional system of TSOs in Quebec in 1998 renewed interest in the role of the TSO here in the United States.3,4 At this time there was a growing body of research indicating that medical errors were a substantial problem and that the majority of errors leading to ABOincompatible transfusions were occurring outside of the laboratory during patient identification, specimen labeling, and blood administration.5 The hospital TSO was proposed as a human solution to improve transfusion safety outside of the laboratory through education, active surveillance of the transfusion process, and participation in implementation of new technology to further enhance patient safety.3,6 Our institution, under leadership of Dr James P. AuBuchon, was an early adopter in the TSO movement with one of the 14 positions identified in the United States 2064 TRANSFUSION Volume 55, September 2015
in 2008.1,7 To illustrate how the field has expanded in recent years, by 2011 there were 201 US hospitals reporting a TSO (15% of hospital-based survey respondents).8 AABB now includes a transfusion safety and patient blood management (PBM) subsection as one of the nine subsections of the transfusion medicine section. This subsection, with more than 400 members, is dedicated to TSOs and others interested in PBM. The emergence of PBM, an evidence-based, multidisciplinary approach to optimize the care of patients who may require transfusion, has created additional areas for involvement of the hospital-based TSO. In 2012 the Joint Commission and the American Medical Association convened a summit on improving patient safety and quality. Unnecessary transfusion of red blood cells (RBCs) was identified as one of the five areas of focus and the work group identified gaps in education as one of the major drivers of variability in transfusion practices. Recommendations included development of educational materials for physicians (risks and benefits of transfusion, evidencebased practice guidelines, and transfusion alternatives) and periodic assessment of provider competency and standardization of performance metrics.9 Around this same time AABB, other professional organizations, and regulatory agencies began actively endorsing and supporting PBM.10-12 The TSO may be identified by a wide variety of titles which may begin with “transfusion,” “blood management,” “hemovigilance,” or “quality” and end with “officer,” “coordinator,” “specialist,” “director,” or “consultant.”13 The TSO facilitates transfusion safety (and ABBREVIATIONS: PBM 5 patient blood management; TSO 5 transfusion safety officer. From the 1Department of Pathology; and the 2Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. Address reprint requests to: Nancy M. Dunbar, MD, One Medical Center Drive, Lebanon, NH 03756-0001; e-mail: Nancy. [email protected]. Received for publication March 13, 2015; revision received April 22, 2015; and accepted April 22, 2015. doi:10.1111/trf.13184 C 2015 AABB V
TRANSFUSION 2015;55;2064–2068
HOW DO I—TSO?
potentially PBM) through education, process review and oversight, and quality improvement efforts across the organization through collaboration with both clinical (health care providers) and technical (laboratory staff) personnel to support evidence-based transfusion practice and ensure patient safety. The TSO scope of practice may include education, monitoring, and reporting on activities related to patient and transfusion safety (patient identification, blood administration, appropriate ordering practices, transfusion reactions, incidents, and near misses), PBM (blood utilization review, minimization of perioperative blood loss, documentation review), quality improvement activities (transfusion guidelines development, transfusion committee or peer review participation, massive transfusion protocols), and research.1 TSOs may come from either a clinical (MD, PA, RN, perfusionist) or laboratory (MT, MLT) background. Those with clinical backgrounds are often very knowledgeable about transfusion indications, blood administration, and patient monitoring and are familiar with the hospital structure and interaction with health care teams but may lack knowledge about laboratory practice and accreditation standards. Conversely, those with a laboratory background understand blood bank testing, transfusion reaction work-ups, and regulatory requirements but may have limited knowledge of the clinical aspects of patient care and fewer interactions with health care teams. Regardless of background, characteristics of successful TSOs include strong communication skills, collaboration, persistence, patience, positivity, and an awareness of and willingness to advocate for best practices.13 There is currently no formal certification required for the TSO role but training programs are available that cover topics such as blood collections, processing and safety, job fundamentals, skill building, and blood management.14 At Dartmouth-Hitchcock Medical Center the first TSO started in 2001 to 2002. This was only after Dr AuBuchon, who was the transfusion medicine director at the time, was able to convince hospital administrators of the need and benefits of the TSO. At that time, the institutional justification included the following potential benefits of this new position:
Extension of the transfusion medicine service quality plan to the bedside; Reduction in errors and improvement in patient safety; Reduction in unnecessary blood component utilization and product wastage resulting in decreased hospital costs; Expansion of nursing and clinician education in transfusion medicine; Improved communication and connectivity between clinical care providers and the transfusion
medicine service to facilitate quality improvement and patient safety initiatives. Since then the role of the TSO has been occupied by four different individuals holding physician assistant or nursing degrees with different clinical backgrounds including perioperative services, apheresis, hematologyoncology, and outpatient services. All of these individuals came to the TSO position with limited knowledge of transfusion medicine yet were all able to gain a very deep understanding of the opportunities and challenges of partnering the transfusion service with clinical counterparts. Our institution-specific TSO training covers the following topics:
Transfusion medicine service operations/policy and procedure review; Audits and blood utilization review; Perioperative blood management; Quality assurance systems and event reporting; Infectious disease management (lookbacks, recalls); Transfusion reaction evaluation, management, and reporting; Clinical orientation and meetings with key stakeholders: clinical nurse specialists, educators, and coordinators; clinical quality resources; and department directors.
At our institution the TSO serves as the primary liaison bridging the transfusion medicine laboratory and the clinical care areas. In this capacity the TSO is available on an as-needed basis to respond to customer concerns and requests for assistance to ensure compliance with established guidelines and policies pertaining to blood component utilization, administration, and documentation. Education of staff involved in blood component transfusion is an area of significant focus. The TSO actively participates in the development of blood component administration policies and procedures, creates training materials for clinical staff, and performs ongoing monitoring to assess competency and compliance. Our TSO also conducts investigations of errors, deviations, and near-miss events that involve blood component administration that occur outside of the laboratory. When areas for improvement are identified, the TSO works with clinical and laboratory staff to develop and lead quality improvement initiatives. As an example, our TSO recently initiated a collaborative project to reduce wastage of RBCs returned from the operating room. This project was in response to a practice change in the blood bank involving implementation of 1 to 68C temperature indicators to allow for return of unused RBCs to inventory. Process development, validation, and implementation required input from a multidisciplinary team that included laboratory technical and supervisory staff working alongside clinical and support Volume 55, September 2015 TRANSFUSION 2065
DUNBAR AND SZCZEPIORKOWSKI
Fig. 1. The transfusion medicine service organizational chart. TSO and quality specialist report to executive management and work closely with medical directors and supervisors in the blood bank (BB) and blood donor program/cellular therapy center (BDP/CTC).
staff from the operating room. Minimization of wastage of RBCs has been achieved by a successful roll-out of the new process and ongoing monitoring of wastage. Interventions to support adherence to the process are led by the TSO on an as-needed basis. At our institution the duties of the TSO are intentionally assigned to allow ample time for both structured and “on-the-fly” clinical staff education, regular participation in meetings with nursing leadership, direct observation of clinical transfusion practice, investigation of events pertaining to blood administration, and participation in or leadership of quality improvement and PBM initiatives. We are fortunate enough to also employ a quality specialist who ensures that the laboratory-based activities of the transfusion medicine service are in compliance with AABB Standards15 and all other applicable laws and regulations. In parallel, the TSO ensures compliance for all activities involving blood component administration that occur outside of the clinical laboratory. As such, the reporting structure for the TSO is similar to that of the
TABLE 1. TSO duties mapped to AABB Standards for Blood Banks and Transfusion Services PROCESS CONTROL 5.11 Samples and requests Educates clinical staff about specimen labeling requirements and investigates mislabeled specimens (5.11.2, 5.11.3) 5.27 Urgent requirement for blood and blood components Reviews all requests for un–cross-matched RBCs and ensures documentation of urgent clinical need provided by ordering physician (5.27.5) 5.28 Administration of blood and blood components Educates and trains clinical staff in administration of blood and blood components Performs quarterly bedside audits of blood administration to ensure: 1. Consent for transfusion is obtained and documented (5.28.1) 2. Order for transfusion is documented (5.28.2) 3. Proper patient and unit identification steps are performed before transfusion (5.28.3, 5.28.4) 4. Patient is observed for adverse events during the transfusion (5.28.6) 5.29 Medical record documentation Reviews nursing documentation of all quarterly bedside audits of blood administration to confirm accurate and complete documentation (5.29.1) DEVIATIONS, NONCONFORMANCES, AND ADVERSE EVENTS 7.4 Adverse events related to transfusion Educates and trains clinical staff in recognition, immediate response and reporting of transfusion reactions (7.4.1.1, 7.4.1.2) Reviews transfusion reaction reports and interpretations and ensures documentation of results for all cultured units are added as an addendum to the clinical note (7.4.2.3) ASSESSMENTS: INTERNAL AND EXTERNAL 8.2 Monitoring Performs audits of RBC transfusions ordering practice to identify providers ordering outside of defined acceptable criteria (ordering practices/appropriateness of use/compliance with peer-review recommendations) Tracks specimen labeling errors by clinical unit (patient identification/sample collection and labeling) Reviews all transfusion reaction reports, tracks reporting rates by clinical unit, reports institutional transfusion reaction data through participation in NHSN Biovigilance (infectious and noninfectious adverse events) Investigates all occurrence reports involving blood or blood component administration (near-miss events) Monitors and reports trends in blood utilization and discard rates (usage and discards) Maintains and updates blood administration policies (blood administration policies) Responds to questions and complaints from the clinical team (ability of services to meet patient needs) Participates in weekly clinical case review of transfusion medicine service (clinically relevant laboratory results) PROCESS IMPROVEMENT THROUGH CORRECTIVE AND PREVENTIVE ACTION 9.1 Corrective action Investigates all occurrence reports and customer complaints related to blood and blood component administration, determines corrective action when indicated, and monitors for effectiveness 9.2 Preventive action Participates in transfusion medicine service administrative team meetings and collaborates with the medical directors, supervisory staff, and quality specialist to identify and remedy potential causes of nonconformances (9.2.1, 9.2.2, 9.2.3)
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HOW DO I—TSO?
TABLE 2. TSO duties mapped to AABB standards for perioperative blood collection and administration RESOURCES 2.1 Human resources Develops and administers annual perioperative program evaluations of competence (2.1.3) PROCESS CONTROL 5.1 General elements Reviews perioperative program quality control results and investigates quality control failures (5.1.2.1) DOCUMENTS AND RECORDS 6.1 Documents Reviews all new and revised perioperative program documents (6.1.3) 6.2 Records Ensures that perioperative program documents are complete and changes are controlled (6.2.1, 6.2.6) DEVIATIONS, NONCONFORMING PRODUCTS OR MATERIALS, AND ADVERSE EVENTS 7.1 Deviations Captures, investigates, and reports all deviations from perioperative program policies, processes, and procedures ASSESSMENTS: INTERNAL AND EXTERNAL 8.2 Quality monitoring Collects and evaluates perioperative program quality indicator data PROCESS IMPROVEMENT 9.2 Preventive action Reviews perioperative program quality control records to detect and analyze potential nonconforming products and materials
quality specialist with both working under the supervision of the medical directors of the transfusion medicine service (Fig. 1). Specific duties routinely performed by the TSO which directly address AABB Standards for Blood Banks and Transfusion Services15 are shown in Table 1. Our TSO also plays an important role in supporting our perioperative RBC recovery program, which is part of our hospital-wide approach to PBM. Specific duties routinely performed by the TSO that directly address AABB Standards for Perioperative Blood Collection and Administration16 are shown in Table 2. The duties of a TSO can be tailored to meet the needs of the institution and the goals of the organization. This year our TSO is involved in multiple hospital-wide projects to improve transfusion safety for our patients including 1) revising the blood component transfusion education module for entering resident physicians to reflect recently revised institutional guidelines for evidence-based transfusion practices, 2) developing and piloting a process improvement project designed to reduce specimen labeling errors at the bedside, and 3) implementation of an alternate mechanical barrier device to prevent mistransfusion of RBCs. Although PBM initiatives at our institution are still in the early stages of development, it is likely that the TSO will continue to be involved with these projects as they evolve. Although great strides have been made in increasing the safety of blood product transfusion by improvements in laboratory testing for infectious diseases,17 significant risks for mistransfusion of blood products remain. Unfortunately, most of the errors related to this type of event continue to occur outside of the control of the clinical laboratory. There remains a significant need for the hospital-based TSO to improve transfusion safety through education, active surveillance of the transfusion process,
and participation in implementation of new technology to further enhance patient safety. As we have demonstrated, many of the activities of the TSO also directly support laboratory compliance with regulatory requirements and maintenance of laboratory accreditation. Finally, as PBM continues to evolve and expand, there will be increasing opportunities for the TSO to facilitate collaborations between the laboratory and the clinical areas to optimize the care of patients who may require transfusion.
ACKNOWLEDGMENT The authors thank James P. AuBuchon, MD, for his involvement in the development of our transfusion safety officer position and for his thoughtful review of this manuscript.
CONFLICT OF INTEREST The authors have disclosed no conflicts of interest.
REFERENCES 1. Johnson ST, Puca KE, editors. Transfusion medicine’s emerging positions: transfusion safety officers and patient blood management coordinators. Bethesda (MD): AABB Press; 2013. 2. Slapak C, Fredrich N, Wagner J. Transfusion safety: is this the business of blood centers? Transfusion 2011;51(12 Pt 2): 2767–71. 3. Dzik WH. Emily Cooley Lecture 2002: transfusion safety in the hospital. Transfusion 2003;43:1190–9. 4. Dzik WH, Corwin H, Goodnough LT, et al. Patient safety and blood transfusion: new solutions. Transfus Med Rev 2003;17: 169–80. Volume 55, September 2015 TRANSFUSION 2067
DUNBAR AND SZCZEPIORKOWSKI
5. Linden JV, Wagner K, Voytovich AE, et al. Transfusion errors in New York state: an analysis of 10 years’ experience. Transfusion 2000;40:1207–13. 6. Lipley N. New transfusion safety role could help cut errors. Nurs Stand 2002;16:9. 7. Szczepiorkowski ZM, AuBuchon JP. The role of physicians in hospital transfusion services. Transfusion 2006;46:862–7. 8. Whitaker B, Hinkins S. The 2011 National Blood Collection and Utilization Survey Report [Internet]. Rockville (MD): US Department of Health and Human Services; 2011 [cited 2015 Feb 20]. Available from: http://www.hhs.gov/ash/bloodsafety/2011-nbcus.pdf 9. Proceedings from the National Summit on Overuse [Internet]. Oakbrook Terrace (IL): The Joint Commission; 2013 Jul 8 [cited 2015 Feb 20]. Available from: http://www.jointcommission.org/overuse_summit/ 10. Patient blood management [Internet]. Bethesda (MD): AABB; c2015 [cited 2015 Feb 20]. Available from: http:// www.aabb.org/pbm/Pages/default.aspx 11. Resource center [Internet]. Richmond, VA: Society for the Advancement of Blood Management; 2005-2014 [cited 2015
2068 TRANSFUSION Volume 55, September 2015
Feb 20]. Available from: http://www.sabm.org/learningresources 12. Clinical Transfusion Medicine Committee and the Scientific Section Coordinating Committee, editors. Guidelines for patient blood management and blood utilization. Bethesda (MD): AABB Press; 2011. 13. McGuinness-Slapak C. Survey conducted and results presented at Nursing II: Patient blood management and transfusion safety workshop. Boston, MA: AABB Annual Meeting; 2012 October 7. 14. Transfusion safety officer training program [Internet]. Scottsdale (AZ): United Blood Services c2008-2015 [cited 2015 Feb 20]. Available from: http://hospitals.unitedbloodservices.org/tso-main.html 15. Standards for blood banks and transfusion services. 29th ed. Bethesda (MD): AABB Press; 2014. 16. Standards for perioperative blood collection and administration. 6th ed. Bethesda (MD): AABB Press; 2014. 17. Perkins HA, Busch MP. Transfusion-associated infections: 50 years of relentless challenges and remarkable progress. Transfusion 2010;50:2080–99.
The hospital transfusion safety officer (TSO) serves an important role in improving transfusion safety outside of the laboratory through education, active surveillance of the transfusion process (patient identification, blood administration, appropriate ordering practices, transfusion reactions, incidents, and near misses), patient blood management (blood utilization review, minimization of perioperative blood loss, documentation review), quality improvement (transfusion guidelines development, transfusion committee or peer review participation, massive transfusion protocols), and research. We provide a description of how we utilize our hospital-based TSO to improve transfusion safety and ensure compliance with regulatory requirements and maintenance of certification at our institution.
T
he modern transfusion safety officer (TSO) evolved from “blood bank nurse coordinator” or “transfusion service liaison” positions that have been in existence in some hospitals since the 1960s.1 The first documented transfusion safety position in the United Stated was at the University of Washington Medical Center in 1962.2 By the year 2000, the modern equivalent of the TSO was well established in France and the United Kingdom and the launch of a successful regional system of TSOs in Quebec in 1998 renewed interest in the role of the TSO here in the United States.3,4 At this time there was a growing body of research indicating that medical errors were a substantial problem and that the majority of errors leading to ABOincompatible transfusions were occurring outside of the laboratory during patient identification, specimen labeling, and blood administration.5 The hospital TSO was proposed as a human solution to improve transfusion safety outside of the laboratory through education, active surveillance of the transfusion process, and participation in implementation of new technology to further enhance patient safety.3,6 Our institution, under leadership of Dr James P. AuBuchon, was an early adopter in the TSO movement with one of the 14 positions identified in the United States 2064 TRANSFUSION Volume 55, September 2015
in 2008.1,7 To illustrate how the field has expanded in recent years, by 2011 there were 201 US hospitals reporting a TSO (15% of hospital-based survey respondents).8 AABB now includes a transfusion safety and patient blood management (PBM) subsection as one of the nine subsections of the transfusion medicine section. This subsection, with more than 400 members, is dedicated to TSOs and others interested in PBM. The emergence of PBM, an evidence-based, multidisciplinary approach to optimize the care of patients who may require transfusion, has created additional areas for involvement of the hospital-based TSO. In 2012 the Joint Commission and the American Medical Association convened a summit on improving patient safety and quality. Unnecessary transfusion of red blood cells (RBCs) was identified as one of the five areas of focus and the work group identified gaps in education as one of the major drivers of variability in transfusion practices. Recommendations included development of educational materials for physicians (risks and benefits of transfusion, evidencebased practice guidelines, and transfusion alternatives) and periodic assessment of provider competency and standardization of performance metrics.9 Around this same time AABB, other professional organizations, and regulatory agencies began actively endorsing and supporting PBM.10-12 The TSO may be identified by a wide variety of titles which may begin with “transfusion,” “blood management,” “hemovigilance,” or “quality” and end with “officer,” “coordinator,” “specialist,” “director,” or “consultant.”13 The TSO facilitates transfusion safety (and ABBREVIATIONS: PBM 5 patient blood management; TSO 5 transfusion safety officer. From the 1Department of Pathology; and the 2Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. Address reprint requests to: Nancy M. Dunbar, MD, One Medical Center Drive, Lebanon, NH 03756-0001; e-mail: Nancy. [email protected]. Received for publication March 13, 2015; revision received April 22, 2015; and accepted April 22, 2015. doi:10.1111/trf.13184 C 2015 AABB V
TRANSFUSION 2015;55;2064–2068
HOW DO I—TSO?
potentially PBM) through education, process review and oversight, and quality improvement efforts across the organization through collaboration with both clinical (health care providers) and technical (laboratory staff) personnel to support evidence-based transfusion practice and ensure patient safety. The TSO scope of practice may include education, monitoring, and reporting on activities related to patient and transfusion safety (patient identification, blood administration, appropriate ordering practices, transfusion reactions, incidents, and near misses), PBM (blood utilization review, minimization of perioperative blood loss, documentation review), quality improvement activities (transfusion guidelines development, transfusion committee or peer review participation, massive transfusion protocols), and research.1 TSOs may come from either a clinical (MD, PA, RN, perfusionist) or laboratory (MT, MLT) background. Those with clinical backgrounds are often very knowledgeable about transfusion indications, blood administration, and patient monitoring and are familiar with the hospital structure and interaction with health care teams but may lack knowledge about laboratory practice and accreditation standards. Conversely, those with a laboratory background understand blood bank testing, transfusion reaction work-ups, and regulatory requirements but may have limited knowledge of the clinical aspects of patient care and fewer interactions with health care teams. Regardless of background, characteristics of successful TSOs include strong communication skills, collaboration, persistence, patience, positivity, and an awareness of and willingness to advocate for best practices.13 There is currently no formal certification required for the TSO role but training programs are available that cover topics such as blood collections, processing and safety, job fundamentals, skill building, and blood management.14 At Dartmouth-Hitchcock Medical Center the first TSO started in 2001 to 2002. This was only after Dr AuBuchon, who was the transfusion medicine director at the time, was able to convince hospital administrators of the need and benefits of the TSO. At that time, the institutional justification included the following potential benefits of this new position:
Extension of the transfusion medicine service quality plan to the bedside; Reduction in errors and improvement in patient safety; Reduction in unnecessary blood component utilization and product wastage resulting in decreased hospital costs; Expansion of nursing and clinician education in transfusion medicine; Improved communication and connectivity between clinical care providers and the transfusion
medicine service to facilitate quality improvement and patient safety initiatives. Since then the role of the TSO has been occupied by four different individuals holding physician assistant or nursing degrees with different clinical backgrounds including perioperative services, apheresis, hematologyoncology, and outpatient services. All of these individuals came to the TSO position with limited knowledge of transfusion medicine yet were all able to gain a very deep understanding of the opportunities and challenges of partnering the transfusion service with clinical counterparts. Our institution-specific TSO training covers the following topics:
Transfusion medicine service operations/policy and procedure review; Audits and blood utilization review; Perioperative blood management; Quality assurance systems and event reporting; Infectious disease management (lookbacks, recalls); Transfusion reaction evaluation, management, and reporting; Clinical orientation and meetings with key stakeholders: clinical nurse specialists, educators, and coordinators; clinical quality resources; and department directors.
At our institution the TSO serves as the primary liaison bridging the transfusion medicine laboratory and the clinical care areas. In this capacity the TSO is available on an as-needed basis to respond to customer concerns and requests for assistance to ensure compliance with established guidelines and policies pertaining to blood component utilization, administration, and documentation. Education of staff involved in blood component transfusion is an area of significant focus. The TSO actively participates in the development of blood component administration policies and procedures, creates training materials for clinical staff, and performs ongoing monitoring to assess competency and compliance. Our TSO also conducts investigations of errors, deviations, and near-miss events that involve blood component administration that occur outside of the laboratory. When areas for improvement are identified, the TSO works with clinical and laboratory staff to develop and lead quality improvement initiatives. As an example, our TSO recently initiated a collaborative project to reduce wastage of RBCs returned from the operating room. This project was in response to a practice change in the blood bank involving implementation of 1 to 68C temperature indicators to allow for return of unused RBCs to inventory. Process development, validation, and implementation required input from a multidisciplinary team that included laboratory technical and supervisory staff working alongside clinical and support Volume 55, September 2015 TRANSFUSION 2065
DUNBAR AND SZCZEPIORKOWSKI
Fig. 1. The transfusion medicine service organizational chart. TSO and quality specialist report to executive management and work closely with medical directors and supervisors in the blood bank (BB) and blood donor program/cellular therapy center (BDP/CTC).
staff from the operating room. Minimization of wastage of RBCs has been achieved by a successful roll-out of the new process and ongoing monitoring of wastage. Interventions to support adherence to the process are led by the TSO on an as-needed basis. At our institution the duties of the TSO are intentionally assigned to allow ample time for both structured and “on-the-fly” clinical staff education, regular participation in meetings with nursing leadership, direct observation of clinical transfusion practice, investigation of events pertaining to blood administration, and participation in or leadership of quality improvement and PBM initiatives. We are fortunate enough to also employ a quality specialist who ensures that the laboratory-based activities of the transfusion medicine service are in compliance with AABB Standards15 and all other applicable laws and regulations. In parallel, the TSO ensures compliance for all activities involving blood component administration that occur outside of the clinical laboratory. As such, the reporting structure for the TSO is similar to that of the
TABLE 1. TSO duties mapped to AABB Standards for Blood Banks and Transfusion Services PROCESS CONTROL 5.11 Samples and requests Educates clinical staff about specimen labeling requirements and investigates mislabeled specimens (5.11.2, 5.11.3) 5.27 Urgent requirement for blood and blood components Reviews all requests for un–cross-matched RBCs and ensures documentation of urgent clinical need provided by ordering physician (5.27.5) 5.28 Administration of blood and blood components Educates and trains clinical staff in administration of blood and blood components Performs quarterly bedside audits of blood administration to ensure: 1. Consent for transfusion is obtained and documented (5.28.1) 2. Order for transfusion is documented (5.28.2) 3. Proper patient and unit identification steps are performed before transfusion (5.28.3, 5.28.4) 4. Patient is observed for adverse events during the transfusion (5.28.6) 5.29 Medical record documentation Reviews nursing documentation of all quarterly bedside audits of blood administration to confirm accurate and complete documentation (5.29.1) DEVIATIONS, NONCONFORMANCES, AND ADVERSE EVENTS 7.4 Adverse events related to transfusion Educates and trains clinical staff in recognition, immediate response and reporting of transfusion reactions (7.4.1.1, 7.4.1.2) Reviews transfusion reaction reports and interpretations and ensures documentation of results for all cultured units are added as an addendum to the clinical note (7.4.2.3) ASSESSMENTS: INTERNAL AND EXTERNAL 8.2 Monitoring Performs audits of RBC transfusions ordering practice to identify providers ordering outside of defined acceptable criteria (ordering practices/appropriateness of use/compliance with peer-review recommendations) Tracks specimen labeling errors by clinical unit (patient identification/sample collection and labeling) Reviews all transfusion reaction reports, tracks reporting rates by clinical unit, reports institutional transfusion reaction data through participation in NHSN Biovigilance (infectious and noninfectious adverse events) Investigates all occurrence reports involving blood or blood component administration (near-miss events) Monitors and reports trends in blood utilization and discard rates (usage and discards) Maintains and updates blood administration policies (blood administration policies) Responds to questions and complaints from the clinical team (ability of services to meet patient needs) Participates in weekly clinical case review of transfusion medicine service (clinically relevant laboratory results) PROCESS IMPROVEMENT THROUGH CORRECTIVE AND PREVENTIVE ACTION 9.1 Corrective action Investigates all occurrence reports and customer complaints related to blood and blood component administration, determines corrective action when indicated, and monitors for effectiveness 9.2 Preventive action Participates in transfusion medicine service administrative team meetings and collaborates with the medical directors, supervisory staff, and quality specialist to identify and remedy potential causes of nonconformances (9.2.1, 9.2.2, 9.2.3)
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HOW DO I—TSO?
TABLE 2. TSO duties mapped to AABB standards for perioperative blood collection and administration RESOURCES 2.1 Human resources Develops and administers annual perioperative program evaluations of competence (2.1.3) PROCESS CONTROL 5.1 General elements Reviews perioperative program quality control results and investigates quality control failures (5.1.2.1) DOCUMENTS AND RECORDS 6.1 Documents Reviews all new and revised perioperative program documents (6.1.3) 6.2 Records Ensures that perioperative program documents are complete and changes are controlled (6.2.1, 6.2.6) DEVIATIONS, NONCONFORMING PRODUCTS OR MATERIALS, AND ADVERSE EVENTS 7.1 Deviations Captures, investigates, and reports all deviations from perioperative program policies, processes, and procedures ASSESSMENTS: INTERNAL AND EXTERNAL 8.2 Quality monitoring Collects and evaluates perioperative program quality indicator data PROCESS IMPROVEMENT 9.2 Preventive action Reviews perioperative program quality control records to detect and analyze potential nonconforming products and materials
quality specialist with both working under the supervision of the medical directors of the transfusion medicine service (Fig. 1). Specific duties routinely performed by the TSO which directly address AABB Standards for Blood Banks and Transfusion Services15 are shown in Table 1. Our TSO also plays an important role in supporting our perioperative RBC recovery program, which is part of our hospital-wide approach to PBM. Specific duties routinely performed by the TSO that directly address AABB Standards for Perioperative Blood Collection and Administration16 are shown in Table 2. The duties of a TSO can be tailored to meet the needs of the institution and the goals of the organization. This year our TSO is involved in multiple hospital-wide projects to improve transfusion safety for our patients including 1) revising the blood component transfusion education module for entering resident physicians to reflect recently revised institutional guidelines for evidence-based transfusion practices, 2) developing and piloting a process improvement project designed to reduce specimen labeling errors at the bedside, and 3) implementation of an alternate mechanical barrier device to prevent mistransfusion of RBCs. Although PBM initiatives at our institution are still in the early stages of development, it is likely that the TSO will continue to be involved with these projects as they evolve. Although great strides have been made in increasing the safety of blood product transfusion by improvements in laboratory testing for infectious diseases,17 significant risks for mistransfusion of blood products remain. Unfortunately, most of the errors related to this type of event continue to occur outside of the control of the clinical laboratory. There remains a significant need for the hospital-based TSO to improve transfusion safety through education, active surveillance of the transfusion process,
and participation in implementation of new technology to further enhance patient safety. As we have demonstrated, many of the activities of the TSO also directly support laboratory compliance with regulatory requirements and maintenance of laboratory accreditation. Finally, as PBM continues to evolve and expand, there will be increasing opportunities for the TSO to facilitate collaborations between the laboratory and the clinical areas to optimize the care of patients who may require transfusion.
ACKNOWLEDGMENT The authors thank James P. AuBuchon, MD, for his involvement in the development of our transfusion safety officer position and for his thoughtful review of this manuscript.
CONFLICT OF INTEREST The authors have disclosed no conflicts of interest.
REFERENCES 1. Johnson ST, Puca KE, editors. Transfusion medicine’s emerging positions: transfusion safety officers and patient blood management coordinators. Bethesda (MD): AABB Press; 2013. 2. Slapak C, Fredrich N, Wagner J. Transfusion safety: is this the business of blood centers? Transfusion 2011;51(12 Pt 2): 2767–71. 3. Dzik WH. Emily Cooley Lecture 2002: transfusion safety in the hospital. Transfusion 2003;43:1190–9. 4. Dzik WH, Corwin H, Goodnough LT, et al. Patient safety and blood transfusion: new solutions. Transfus Med Rev 2003;17: 169–80. Volume 55, September 2015 TRANSFUSION 2067
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5. Linden JV, Wagner K, Voytovich AE, et al. Transfusion errors in New York state: an analysis of 10 years’ experience. Transfusion 2000;40:1207–13. 6. Lipley N. New transfusion safety role could help cut errors. Nurs Stand 2002;16:9. 7. Szczepiorkowski ZM, AuBuchon JP. The role of physicians in hospital transfusion services. Transfusion 2006;46:862–7. 8. Whitaker B, Hinkins S. The 2011 National Blood Collection and Utilization Survey Report [Internet]. Rockville (MD): US Department of Health and Human Services; 2011 [cited 2015 Feb 20]. Available from: http://www.hhs.gov/ash/bloodsafety/2011-nbcus.pdf 9. Proceedings from the National Summit on Overuse [Internet]. Oakbrook Terrace (IL): The Joint Commission; 2013 Jul 8 [cited 2015 Feb 20]. Available from: http://www.jointcommission.org/overuse_summit/ 10. Patient blood management [Internet]. Bethesda (MD): AABB; c2015 [cited 2015 Feb 20]. Available from: http:// www.aabb.org/pbm/Pages/default.aspx 11. Resource center [Internet]. Richmond, VA: Society for the Advancement of Blood Management; 2005-2014 [cited 2015
2068 TRANSFUSION Volume 55, September 2015
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