Peo ae kee ee ed
Assessment Scoring Matrix
Standard 18. COP-1: Emergency services are guided by policies, procedures and
applicable laws and regulations.
5 Max.
Indicators 58-61 Max. |weightage|
ind sa, | SOPSfor emergency care including handling 10
* | medicolegal cases are documented and available.
ind 59, | SOPS Suide the prioritization of patients for initiation of | 4
appropriate care.
Staff members are familiar with the SOPs for care of
Ind 60. | emergency patients and trained on the same and the 10
patients receive care in consonance with the SOPs.
Ind61. Admission, discharge or referral to another HCE is 10
documented.
Total 40
Punjab Healthcare CommissionStandard 19. COP-2: Policies and procedures define rational use of blood and
blood products.
Indicators (62-65):
PACU Pr ace ee or)
Reenter kets marek oee cel ee
Survey Process:
While visiting the blood bank review the SOPs/manual which should be in line with the approved guidelines
and at least cover: i, Donor screening, i, Processing of blood, ll. Storage of blood, iv. Administration of blood, v.
Use of blood products, vi Identification and analysis of real or suspected transfusion reactions and vii. Disposal
of blood and related products. (See Standards & Guidelines for Blood Establishments Punjab 2015 published by
PBTA, Health Department, Government of Punjab)
Look for compliance with the documented SOPs and discuss with staff and also review the staff training records.
Scoring:
Ifthe SOPs are present in the blood bank, they include at least the above 7 requirements (relevant to the
scope of services available in the hospital) and staff has been trained to apply those, then score as fully met.
Since blood services are critical patient safety issue, if any of the 7 requirements (relevant to the scope of
service in the hospital) are not present or if the staff has not been trained to apply them, then score as not
met.
Standard Operating Procedure (SOP)
Blood Transfusion
a, Blood Screening
WHO recommends protocols for screening all donated blood for five Blood Transmitted
Infections namely Hepatitis B and C, HIV, Malaria and Syphilis, and this should be practiced.
b. Processing of Donated Blood
Blood collected in an anticoagulant can be stored and transfused to a patient in an
unmodified state. This is known as ‘whole blood transfusion. However, blood may be used
more effectively if component therapy is practiced. One unit of donated blood may be
ivided into components, including red cell concentrates, fresh frozen plasma,
cryoprecipitate and platelet concentrates, to meet the needs of more than one patient.The
following elements are essential for safe and effective blood component processing:
1. Commitment and support by health authorities for sustainable, well-organized,
coordinated blood transfusion services, with adequate resources and quality system
for all areas.
2. Centralization of blood processing and testing within major centers to permit
economies of scale by maximizing utilization of personnel and equipment and
enforcing uniform standards
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3. Effective and timely testing of all donated blood to ensure maximum safety and
availability of blood components.
4. Promotion of appropriate blood component therapy.
5. Using surplus plasma for the production of plasma-derived medicinal products
through fractionation,
Storage and Collection of Blood from Blood Refrigerator
a. Incorrect collection, labelling and storage of blood are the major source of errors
leading to transfusion of wrong blood
b. Blood is to be stored only in designated blood refrigerators or blood boxes, and never
efrigerators