Standard 7: Blood Management

Storing, distributing and tracing blood and blood products

Action 7.9

The health service organisation has processes:  

a. That comply with manufacturers’ directions, legislation, and relevant jurisdictional requirements to store, distribute and handle blood and blood products safely and securely

b. To trace blood and blood products from entry into the organisation to transfusion, discard or
transfer

Intent

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

Reflective questions

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?

Key tasks

  • 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.

Strategies for improvement

Hospitals

Manufacturers, suppliers, the TGA, distributors, other stakeholders, and states and territories have directions, legislation and relevant requirements relating to storing, distributing and handling blood and blood products safely and securely. Follow these to ensure the safety and quality of the products. Failure to meet the requirements may result in degradation in product quality, and increased risk of patient morbidity or mortality.

Ensure that policies, procedures or protocols are in place relating to the management of blood and blood products, including traceability, receipt, storage, collection and transport of blood and blood products (see Action 7.1). These should cover how products are ordered, receipted, stored, handled and transported in the facility, and include refrigeration protocols, the inventory management process and cold chain integrity.

To identify potential risks in systems:

  • Assess compliance with policies, procedures and protocols relating to the management of blood and blood products (as required in Action 7.1)
  • Regularly review reports on traceability, receipt, collection, storage and transport of blood and blood products within the organisation
  • Monitor incidents relating to traceability, receipt, storage, collection and transport of blood and blood products, and identify recurring issues
  • Monitor inventory levels to ensure product availability to meet clinical demand
  • Monitor wastage of blood and blood products (as required under Action 7.10)
  • Review the risks identified against the reports from the blood and blood product management systems, such as refrigeration temperature registers or reports and temperature loggers.

If possible, use electronic systems (for example, BloodNet) to monitor receipt, transfer and fate (including wastage) of blood and blood products.

Provide orientation and training to all members of the workforce involved in the management of blood and blood products, including ordering, traceability, receipt, storage, collection and transport of blood and blood products.

Where the provision of blood and blood products within an organisation is outsourced, ensure that contracts with providers include requirements to address the strategies identified, and to provide sufficient information to confirm these are implemented. Monitor compliance of the blood management provider with these strategies.

Day Procedure Services

Applicability of actions

The actions in the Blood Management Standard will not be applicable for day procedure services that do not use blood or blood products. These services should provide evidence that they do not use, receive, store, collect or transport the blood or blood products governed under this standard.

Services using blood or blood products should refer to the information provided for hospitals for blood management.

MPS & Small Hospitals

MPSs or small hospitals that use blood or blood products should:

  • Review the risks associated with traceability, receipt, storage, collection and transport of blood and blood products
  • Provide training to the workforce about 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; processes and policies should comply with manufacturers, suppliers, the TGA, distributors, other stakeholders, and state and territory directions, legislation and relevant requirements relating to the safe and secure storage, distribution and handling blood and blood products.

To identify potential risks in systems:

  • Assess compliance with policies, procedures and protocols relating to the management of blood
  • and blood products (as required in Action 7.1)
  • Regularly review reports on traceability, receipt, collection, storage and transport of blood and blood products within the organisation
  • Monitor incidents relating to traceability, receipt, storage, collection and transport of blood and blood products, and identify recurring issues
  • Monitor inventory levels to ensure product availability to meet clinical demand
  • Monitor wastage of blood and blood products (as required under Action 7.10)
  • Review the risks identified against the reports from the blood and blood product management systems, such as refrigeration temperature reports and temperature loggers.

If possible, use electronic systems (for example, BloodNet) to monitor receipt, transfer and fate (including wastage) of blood and blood products.

Last updated 30th May, 2018 at 01:31am
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