BLOOD BANK 4th EDITION

Blood Bank
What
Measure Category (Clinical) and QPS Standard/Measurable element
S. No.
Standard PM Name Numerator Denominator Multiplication
factor

Percentage of
1 CQI 3f transfusion Numerator Denominator 100
reactions
JAN Numerator Denominator 100
FEB Numerator Denominator 100
MAR Numerator Denominator 100
APR Numerator Denominator 100
MAY Numerator Denominator 100
JUNE Numerator Denominator 100
July 0
Aug 0
Sep 0
Oct 0
Nov 0
Dec 0

What
Measure Category (Clinical) and QPS Standard/Measurable element
S. No.
Standard PM Name Numerator Denominator Multiplication
factor

Percentage of Number of Number of

wastage of Blood & Blood blood & blood
2 CQI 3f blood and components components 100
blood wasted among issued from
components those issued the blood bank
Jan 0 100
Feb 0 100
Mar 0 100
Apr 0 100
May 0 100
June 0 100
July 0 100
Aug 0 100
Sep
Oct
Nov
Dec

Page 1
 BLOOD BANK 4th EDITION

What
Measure Category (Clinical) and QPS Standard/Measurable element
S. No.
Standard PM Name Numerator Denominator Multiplication
factor

Percentage of Number of Number of

3 CQI 3f blood blood blood & Blood 100
component components components
usage used prepared
Jan 100
Feb 100
Mar 100
Apr 100
May 100
June 100
July 100
Aug 100
Sep 100
Oct 100
Nov 100
Dec 100

What
Measure Category (Clinical) and QPS Standard/Measurable element
S. No.
Standard PM Name Numerator Denominator Multiplication
factor

Turnaround Total number

time for issue of blood and
4 CQI 3f of blood and Sum of time blood 1
blood taken components
components issued
Jan 1
Feb 1
Mar 1
Apr 1
May 1
June 1
July 1
Aug 1
Sep 1
Oct 1
Nov 1
Dec 1

Page 2
 BLOOD BANK 4th EDITION

Blood Bank
What Type of
and QPS Standard/Measurable element Measure
Who (Indicator)
Measure (Owner-Staff Process/ Sample Size
(Indicator) Original name/Title) Outcome/
Result Target/Thresh Unit Source of Structure/
old/Benchmar measure Process
k outcome
Patient files /
transfusion Incharge Blood Continuous
#REF! % Bank Out come 100%
forms
0
0
0.8
0.0
2.1
0.0

Type of
What Measure
and QPS Standard/Measurable element (Indicator)
Who
Measure (Owner-Staff Process/ Sample Size
(Indicator) Original name/Title) Outcome/
Result Target/Thresh Unit Source of Structure/
old/Benchmar measure Process
k outcome
Blood Bank &
#REF! ≤2.5 % Patient care Incharge Blood Outcome 100%
areas Bank

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0

Page 3
 BLOOD BANK 4th EDITION

What Type of
and QPS Standard/Measurable element Measure
Who (Indicator)
Measure (Owner-Staff Process/ Sample Size
(Indicator) Original name/Title) Outcome/
Result Target/Thresh Unit Source of Structure/
old/Benchmar measure Process
k outcome
Blood Bank & Incharge Blood Process&outco
#REF! >/= 95 % Patient care Bank me 100%
areas
100
100
100
100
100
100
100
100
100
100
100
100

What Type of
and QPS Standard/Measurable element Measure
Who (Indicator)
Measure (Owner-Staff Process/ Sample Size
(Indicator) Original name/Title) Outcome/
Result Target/Thresh Unit Source of Structure/
old/Benchmar measure Process
k outcome

#REF! 120 min Blood bank Incharge Blood Process 30%

Bank

Page 4
BLOOD BANK 4th EDITION

Page 5
BLOOD BANK 4th EDITION

Page 6
 BLOOD BANK 5th EDITION

Blood Bank
PSQ3a. Percentage of transfusion reactions
Measure Category (Clinical) and QPS Standard/Measurable element
Measure (Indicator)
Target/Threshold/Benchmark - 3%
Original Source of measure- Patient files /
transfusion forms
S. No. Sample Size- Continuous 100%

Denominat Multiplicati
Standard Numerator Result
or on factor

Total Total
1 PSQ3a number of number of 100 #REF!
transfusion units
reactions transfused
Jan 100
Feb 100
Mar 100
Apr 100
May 100
June 100
July 100
Aug 100
Sep 100
Oct 100
Nov
Dec

PSQ3c. Turnaround time for issue of blood and blood componen

Measure Category (Clinical) and QPS Standard/Measurable element
Measure (Indicator)
Target/Threshold/Benchmark - 40min
Original Source of measure- Blood bank
S. No. Sample Size- 100%

Page 7
S. No. BLOOD BANK 5th EDITION

Denominat Multiplicati
Standard Numerator Result
or on factor

Total
number of
blood and
Sum of time blood
2 PSQ3c 1 #REF!
taken components
cross
matched/re
served
Jan 1
Feb 1
Mar 1
Apr 1
May 1
June 1
July 1
Aug 1
Sep 1
Oct 1
Nov 1
Dec 1

Page 8
 BLOOD BANK 5th EDITION

fusion reactions
urable element
Measure (Indicator) Type of
Measure
easure- Patient files / Who (Indicator)
(Owner-
s 100% Staff
name/Title) Process/
Outcome/
Unit Structure/
Process
outcome

Incharge
% Out come
Blood Bank

ood and blood components

urable element
Measure (Indicator) Type of
Measure
re- Blood bank Who (Indicator)
(Owner-
Only includes PRBC
Staff
name/Title)

Page 9
 Who
(Owner-
Only
BLOOD includes
BANK PRBC
5th EDITION
Staff
name/Title) Process/
Outcome/
Unit Structure/
Process
outcome

Incharge
min Process
Blood Bank

Page 10
 TR

Auditor Name & ID

Month-

Date & time of

Date & time of issue Date & Time of
Age/Sex Location/Ward Reporting to blood
of blood component transfusion reaction
bank

7 YRS/F PICU

Auditor Name & ID

Month-

Date & time of issue of Date & Time of

MRN Age/Sex Location/Ward
blood component transfusion reaction
307429 2YRS/F

Page 11
 TR

Date & time of receiving fresh

Reason for reaction Corrective & Preventive action taken
blood sample in Blood Bank

Date & time of Reporting to Date & time of receiving fresh

Reason for reaction
blood bank blood sample in Blood Bank

Page 12
 TR

Corrective &
Preventive
action taken

Page 13
 TAT

Collection tool to monitor Turn around time for issue of b

de: PSQ3c

Measure Description: Turn around time for issue of blood components

Sample Size- 100 %

Component Type
S No. Name of the Patient MRN Type Location/Ward (Routine/
Emergency)

1 B/O PRERNA SAWANT 309757 PRBC NICU ROUTINE

2 B/O NITI MUSALE 310270 PRBC NICU ROUTINE
3 B/O NITI MUSALE 310270 PRBC , FFP NICU ROUTINE
4 B/O RASHMI BHANDARI 309031 PRBC NICU ROUTINE
5 SHRISHTI GUPTA 310296 PRBC PICU ROUTINE
6 YUKTI SAJNANI 310308 PRBC PICU ROUTINE
7 SIA SOLANKI 310314 PRBC PICU ROUTINE
8 B/O NITI MUSALE 310270 PRBC NICU ROUTINE
9 SHRISHTI GUPTA 310296 PRBC PICU ROUTINE
10 B/O HANSA PATEL 310339 PRBC NICU ROUTINE
11 AARADHYA GHADI 309148 PRBC NICU ROUTINE
12 TRIDHA JADAV 310361 PRBC TWIN ROUTINE
13 GEETA SHAH 310357 RDP ICU ROUTINE
14 GEETA SHAH 310357 SDP ICU ROUTINE
15 GEETA SHAH 310357 SDP ICU ROUTINE
16 B/O SHEETAL JAIN 309658 PRBC NICU ROUTINE
17 B/O NITI MUSALE 310270 PRBC NICU ROUTINE
18 REYANSH KAMBLE 310426 PRBC PICU ROUTINE
19 B/O KAVI PATHAK 310440 PRBC NICU ROUTINE
20 SHIKHA JAISWAL 310595 PRBC FETAL GYNAC ROUTINE
21 MAST MOHD TAMIM 310463 PRBC PICU ROUTINE
22 HARAK JAIN 310467 PRBC SINGLE AC ROUTINE
23 B/O AVIVA DUA 310021 PRBC NICU ROUTINE
24 ANISHA NILJIKAR 310481 PRBC ICU ROUTINE
25 ANISHA NILJIKAR 310481 PRBC ICU ROUTINE
26 B/O JENIE MEHTA 310030 PRBC NICU ROUTINE
27 URMILA TIWARI 310419 PRBC SINGLE AC ROUTINE
28 BABY AADHYA SANGVI 310515 PRBC PICU ROUTINE
29 B/O NITI MUSALE 310270 PRBC NICU ROUTINE
30 SHIKHA JAISWAL 310595 PRBC TWIN ROUTINE
31 B/O SHIKHA JAISWAL 310596 PRBC,FFP NICU ROUTINE
32 B/O NITI MUSALE 310270 PRBC NICU ROUTINE
33 SAIYAMI DEULKAR 310476 PRBC PICU ROUTINE

Page 14
 TAT
34 B/O SHIKHA JAISWAL 310596 RDP NICU ROUTINE
35 SUSHIL ARORA 310651 PRBC ICU ROUTINE
36 SUSHIL ARORA 310651 SDP ICU ROUTINE
37 SUSHIL ARORA 310651 PRBC ICU ROUTINE
38 B/O SHIKHA JAISWAL 310596 PRBC NICU ROUTINE
39 B/O NITI MUSALE 310270 PRBC NICU ROUTINE
40 B/O SHIKHA JAISWAL 310596 PRBC NICU ROUTINE
41 AMINA SHAIKH 310710 PRBC PICU ROUTINE
42 B/O ANMOL PABALE 310694 PRBC,FFP PICU ROUTINE
43 B/O SHEETAL JAIN 309658 PRBC NICU ROUTINE
44 SATISH KELSIKAR 310686 PRBC ICU ROUTINE
45 SARITA SINGH 310724 PRBC SINGLE AC ROUTINE
46 SARITA SINGH 310724 PRBC SINGLE AC ROUTINE
47
48
49
50
51
52

Page 15
 TAT

r Turn around time for issue of blood components

Auditor Name & ID
Month-JANUARY 2024

Date of Time of Date of Time of

request request component component Reason for Corrective &
received in received in reaching the reaching the T2 – T 1 delay if any Preventive
Blood Bank Blood Bank clinical unit clinical unit action taken

01/01/24 9.30AM 01/01/24 9.45AM

01/01/24 10.33AM 01/01/24 11.18AM
01/01/24 4.33PM 01/01/24 4.41PM
01/01/24 5.43PM 01/01/24 5.50PM
01/02/24 11.45PM 01/02/24 12.05AM
01/03/24 12.54PM 01/03/24 2.00PM
01/03/24 2.00PM 01/03/24 2.10PM
01/04/24 10.30AM 01/04/24 10.44AM
01/04/24 1.30PM 01/04/24 2.32PM
01/04/24 11.51AM 01/04/24 12.05PM
01/06/24 11.52AM 01/06/24 12.00PM
01/06/24 12.56PM 01/06/24 2.05PPM
01/06/24 10.35AM 01/06/24 10.42AM
01/07/24 11.17AM 01/07/24 2.02PM
01/08/24 2.47PM 01/08/24 4.10PM
01/09/24 9.50AM 01/09/24 10.05AM
01/10/24 12.09PM 01/10/24 12.23PM
01/11/24 11.20AM 01/11/24 12.45PM
01/12/24 9.42AM 01/12/24 6.04PM
01/12/24 9.00PM 01/12/24 9.30PM
01/13/24 4.51PM 01/13/24 4.57PM
01/13/24 4.42PM 01/13/24 6.18PM
01/14/24 12.35AM 01/14/24 12.45AM
01/14/24 4.51 PM 01/14/24 4.55PM
01/14/24 5.18PM 01/14/24 5.20PM
01/15/24 11.58AM 01/15/24 12.09PM
01/16/24 4.42PM 01/16/24 4.50PM
01/17/24 3.20PM 01/17/24 3.33PM
01/19/24 11.35AM 01/19/24 11.40AM
01/21/24 5.01PM 01/21/24 5.08PM
01/21/24 5.35PM 01/21/24 6.10PM
01/23/24 10.07AM 01/23/24 10.10AM
01/23/24 9.37AM 01/23/24 9.45AM

Page 16
 TAT
01/24/24 10.58AM 01/24/24 11.40AM
01/24/24 7.12PM 01/24/24 7.50PM
01/24/24 9.27PM 01/24/24 9.32PM
01/25/24 9.27AM 01/25/24 9.32AM
01/25/24 11.03AM 01/25/24 11.15AM
01/26/24 6.10AM 01/26/24 6.30AM
01/27/24 6.31PM 01/27/24
01/27/24 6.33PM 01/27/24 8.25PM
01/28/24 3.51PM 01/28/24 4.00PM
01/29/24 10.57AM 01/29/24 11.05AM
01/30/24 9.28AM 01/30/24 10.04AM
01/30/24 2.27PM 01/30/24 2.32PM
01/31/24 8.28AM 01/31/24 9.02AM

Page 17
 TAT

Page 18
 TAT

Page 19
 TAT

Page 20