Performance Improvement (PI) Monitoring

INTENT (EXPECTED OUTCOMES)

All patients who receive DRBC transfusions have accurate documentation in the medical record of the quantity of transfused blood and any transfusion-related adverse events.

PERFORMANCE/ADHERENCE MEASURES

- In patients who were transfused DRBCs, there was accurate documentation, including time of transfusion and all transfused blood products annotated on the blood transfusion form (Appendix B) in the medical record and any transfusion-related adverse events.
- Accurate Documentation:
  - Document number of units transfused
  - Document time of transfusion (on 518 form and in clinical record)
  - Document number of DRBC transfused
  - Document transfusion reaction

DATA SOURCE

- Patient Record
- DoD Trauma Registry
- Combatant Command blood bank logs
- Theater Medical Data Store or its successor

SYSTEM REPORTING & FREQUENCY

The above constitutes the minimum criteria for PI monitoring of this CPG. System reporting will be performed twice a year; additional PI monitoring and system reporting may be performed as needed.

The system review and data analysis will be performed by the JTS Chief and the JTS PI team.

RESPONSIBILITIES

It is the combined responsibility of the trauma team leader and blood bank officer to ensure familiarity, appropriate compliance, and PI monitoring at the local level with this CPG.