Blood Management Standard

Safety and quality systems support clinicians in blood management.

• How are the health service organisation’s safety and quality systems used to:
  • support implementation of policies and procedures for blood management
  • identify and manage risks associated with blood management
  • identify training requirements for blood management?

• Ensure that governance structures are in place for blood management
• Develop and implement policies and procedures for blood management
• Use organisation-wide risk management systems to identify, monitor, manage and review risks associated with blood management
• Deliver or provide access to training on blood management based on the specific needs of the clinical workforce.

Quality improvement systems are used to support blood management.

• How is the effectiveness of the blood management system continuously evaluated and improved?
• How are the outcomes of improvement activities reported to the governing body, the workforce and consumers?

• Review, measure, and assess the effectiveness and performance of, organisational and clinical strategies for blood management
• Implement quality improvement strategies for blood management based on the outcomes of monitoring activities
• Provide information on the outcomes of quality improvement activities to the governing body, the workforce, consumers and other organisations.

Patients and carers are informed about patient blood management principles, the risks and benefits of using blood and blood products, and all treatment options.

• What processes from the Partnering with Consumers Standard do clinicians use to involve patients in planning and making decisions about safe blood management?
• How does the health service organisation collect feedback from patients about information provided on safe blood management?

How does the health service organisation involve patients in decisions about their care and confirm their consent to treatment?

• Review strategies in the Partnering with Consumers Standard to inform the implementation of actions in the Blood Management Standard
• Provide information to patients about patient blood management principles, the risks and benefits of using blood and blood products, and all treatment options, that is tailored to their specific needs and level of health literacy.

Patient blood management (PBM) strategies are in place to ensure that the clinical use of blood and blood products is appropriate and safe, and strategies are used to reduce the risks associated with transfusions.

• How are patients who are at risk of substantial blood loss identified and managed?
• What PBM strategies are used for optimising patients’ own red cell mass, haemoglobin and iron stores?
• Who is responsible for planning and overseeing PBM plans?

• Develop effective PBM strategies
• Identify, develop and implement policies, procedures and protocols for PBM to optimise and conserve the patient’s own blood, and manage the need for blood and blood products
• Develop and implement education activities for PBM to optimise and conserve the patient’s own blood, and manage the need for blood and blood products
• Establish perioperative standard practice for assessment and management of anaemia
• Implement processes to communicate elective surgical time frames to patients’ primary carers to enable effective anaemia management in the primary care sector, if possible.

The history of blood product use, and relevant clinical and product information are documented in the patient’s healthcare record to minimise risks and optimise clinical outcomes.

• How does the health service organisation ensure that a comprehensive history of blood product use, transfusion history, optimising a patient’s own blood and assessing the patient’s bleeding risk are documented in the patient’s healthcare record?
• What processes are used to document adverse reactions to blood or blood products in the patient’s healthcare record?

• Document comprehensive information, including blood use, transfusion history and transfusion details, before, during and after transfusions
• Develop and implement education activities for the workforce responsible for PBM about documenting transfusion of blood or blood products in the patient’s healthcare record, recognising and responding to adverse transfusion reactions, and documenting adverse reactions in the patient’s healthcare record.

Systems are in place to ensure that the clinical use of blood and blood products is appropriate, and strategies are used to reduce the risks associated with transfusions.

How does the health service organisation ensure that protocols for prescribing and administering blood and blood products are consistent with national guidelines and national criteria?

• Develop and implement policies, procedures and protocols that are evidence based, and in line with national guidelines and criteria for the prescription and administration of blood and blood products
• Ensure that clinicians have the necessary skills to prescribe and administer blood and blood products
• Develop and implement education activities for the prescription and administration of blood and blood products.

Transfusion-related adverse events are reported to enable identification of previous adverse reactions or special transfusion requirements, and to drive improvement opportunities.

• How are blood management incidents reported and managed?
• To whom does the health service organisation report adverse reactions to blood and blood products?

• Capture blood-related incidents in incident management and investigation systems, and provide reports from these systems to the blood management governance group to inform activities in the blood management quality improvement system (see Action 7.02)
• Provide a summary analysis of blood- and blood product–related incidents to the highest level of governance in the organisation for review and action
• Report transfusion adverse events in accordance with regulator and supplier requirements, as well as local policies and procedures
• Develop and implement education activities for reporting transfusion-related adverse events in accordance with national guidelines and criteria.

The health service organisation participates in relevant haemovigilance activities to improve the effective and appropriate management of blood and blood products, and to ensure the safety of people receiving and donating blood.

• To whom does the health service organisation report internally and externally on haemovigilance activities?
• How does the health service organisation ensure that this reporting is consistent with the national framework?

• Identify and implement processes to take part in haemovigilance programs for health service organisations, local health networks or private hospital groups, state or territory programs or national programs
• Develop and implement education activities for haemovigilance programs.

Blood and blood products are managed appropriately to ensure that they are available and safe for clinical needs.

• How does the health service organisation ensure that processes for the receipt, storage, collection and transport of blood and blood products are consistent with best practice and national guidelines?
• How are blood or blood products tracked within the health service organisation?

• Regularly review the risks associated with traceability, receipt, storage, collection and transport of blood and blood products
• Provide training to the workforce on safe blood management
• Review policies, procedures and protocols for addressing risks identified with receipt, collection, storage, handling and transport of blood and blood products, and review reports from inventory management and supply chain systems.

Blood and blood products are managed to minimise wastage and ensure that product is available to meet clinical demand in times of shortage.

• How is the availability of blood products monitored?
• What processes are in place to minimise blood wastage?
• What contingency arrangements are in place for blood products?

• Regularly review the risks associated with availability of blood and blood products, including minimising wastage and responding in times of shortage, and develop policies and processes to respond to these risks
• Provide training to the workforce about ensuring blood availability
• Record wastage in a system and monitor wastage reports
• Regularly review inventory requirements, and manage blood and blood products to ensure availability
• Identify, develop and implement contingency arrangements, including planning for times of supply shortage, considering state or territory and national arrangements.