Section II. PEER REVIEW
2-4. GENERAL
a. Peer review is the process by which a selected group of physicians and other
hospital staff members review services within a hospital using a set of predetermined
criteria. The main goal of the peer review is the improvement of the hospital's quality of
services.
b. The hospital transfusion committee performs the review of the hospital's
transfusion practice. This committee establishes written criteria for analyzing
justification for transfusion. The blood usage review is an accreditation requirement for
a transfusion service. All transfusions are reviewed for documentation of appropriate
blood product's use consistent with established written criteria. The findings and/or
activities of the transfusion committee must be properly documented and reports
forwarded to other hospital committee services, departments, and hospital staff.
c. Peer review of blood product transfusion practices is a requirement of the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO), the Code of
Federal Regulation for a hospital to qualify to received Medicare reimbursement (HCFA-
Health Care Financing Administration), the College of American Pathologist (CAP),
and the American Association of Blood Banks (AABB) as part of their inspection and
accreditation process.
2-5. ORGANIZATION OF THE BLOOD USAGE REVIEW COMMITTEE
(TRANSFUSION COMMITTEE)
a. The members of the transfusion committee and the chairman are, in most
instances, appointed by the hospital commander and by recommendations received
from the departments chief. Members to the committee should include personnel from
the departments that have the requirement for blood products, such as: surgery,
medicine, anesthesiology, obstetrics, and pediatrics. Others members may include a
hospital administrator, nursing, medical records, transfusion services' medical director,
and a blood bank representative.
b. The members of the transfusion committee should have some knowledge and
experience in one or more aspects of transfusion therapy and blood banking.
2-6. JCAHO REQUIREMENTS
a. The transfusion committee must meet at least quarterly to review blood usage
practices.
b. The blood usage review must include the following:
(1) The review of usage of all categories of blood products.
MD0868
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