Purpose:

• To play a central role in the strategic, operational, and reporting lines for transfusion safety, implementation of Patient Blood Management initiatives, and management of blood supply and use in hospitals.

 

Functions of the Committee:

• Monitoring the usage of blood and blood components within the hospital
• Reducing blood component loss due to time expiry and other wastage reasons
• Monitoring, reporting, and investigating transfusion adverse events and near misses and using these experiences to promote learning
• Reduce the number of incidents in which an inappropriate dose of a component is given to a patient
• Analyze all recall incidents
• Training and assessment for all staff in the hospital that are involved in the blood transfusion process
• Developing systems for the implementation of national guidelines within the hospital
• Defining blood transfusion policies
• Preparation and approval of transfusion manual
• Liaison with blood transfusion services to ensure the availability of required blood and blood components

 

Constitution of the committee:

Chairman:    Director of Medical Services

Convener:    Registrar – Blood Bank

Members:   

Deputy Medical Superintendent

Associate Consultant- Endocrine Surgery

Consultant – Orthopaedics

Junior Consultant- Emergency

Senior Consultant- CTVS

Consultant – OBG

AGM Nursing

Quality Manager

 

Role of Chairperson

• Acts as a liaison between the Blood Transfusion Committee and the Apollo Adlux Governance Committee chairperson
• Receives all the information pertaining to BTC and initiates necessary action as required.
• Keep oneself abreast with the recent developments in the field.

 

Role of Convener

• Prepare the agenda for the next meeting
• Submission for approval of agenda by the chairperson
• Inform the committee members regarding the next meeting at least 2 days before the meeting
• The minutes of the meeting shall be prepared by the Convener
• Get the approval of minutes from the chairperson
• Circulate the agenda approved by the chairperson to the members and the concerned persons
• To maintain all records (as per the list) related to the committee
• Submission of a copy of the agenda and the minutes of the meeting to the quality department after getting signatures from all the concerned members

 

Frequency of meeting:

The committee shall meet once quarterly, and on an urgent basis whenever required.

 

Quorum of Committee:

The quorum for the meeting is 50% of the members with the chairperson being mandatory and that for passing any resolution is 2/3rd of the members.

If such a quorum is not present within 15 minutes of the appointed time, the Chairman will decide to re-schedule the meeting.

If the Chairperson is unable to attend the meeting / has to leave during the meeting for valid reasons like a medical and administrative emergency: The Chairperson will delegate the responsibility to any clinical member of the committee, prior to the meeting.

If any member of the committee is unable to attend for valid reasons then the same should be intimated to the convenor via e-mail & he/she can designate an alternate to represent him/her in the meeting

Decision-making is done through the consensus of members and experts when called in.

The committee meeting can be conducted physically or through teleconferencing technology through Microsoft teams

 

Notice of Meetings:

Notice of the Committee meetings will be delivered at least five days in advance of the meetings.

As appropriate, different methods of notification may be used: e-mail, phone, or hand delivery.

Notice for the meeting will include the date, time, place,5 and agenda of the meeting.

Notice of any special meeting will be given at least five days prior to the meeting unless the special meeting is called for a time when the giving of 5 days’ notice is impossible.

 

Records of Meeting

Records of the meeting include the Attendance log, Agenda, Minutes of the meeting & other supporting documents related to the minutes of the meeting.

Attendance: Attendance of the committee members will be recorded as per the standard format shared by the Quality department of the unit.

Agenda:  The agenda of the meeting shall be limited to the purpose for which it was called. The minimum agenda for the Blood Transfusion Committee meeting may include:

• Review of previous minutes of the meeting
• Discussion on Blood component usage analysis
• Presentation of Blood Bank quality indicators
• Presentation of analysis of blood transfusion-related incidents
• Training status for all staff involved in the blood transfusion process
• Any other topics pertaining to the blood bank department

 

Minutes of the meeting:

Format for the meeting minutes

Agenda:

Discussion:

Action Plan:

Responsibility:                                                                 Deadline:

The appointed committee convener will prepare a draft of the minutes of the meeting and circulate it to all the committee members after approval from the committee Chairperson.

Minutes of meeting to be circulated within 2 working days

The approved agenda, attendance log, minutes, and any reports/materials related to the discussions are maintained as hard copies /soft copies with the Quality department.

Retention of meeting records: The records shall be maintained for a period of 5 years. Destruction of records shall be done by shredding

 

Records:

• The TOR of the committee
• Minutes of the meeting
• Attendance Sheet
• Records shall be retained for a period of 5 years including the minutes of the meeting
• Blood bank quality indicators

 

Operational Policy

Tenure: The tenure of appointment as a committee member is for two (2) years (Subject to attendance).

Reporting To: Governance Committee

Appointment:

The committee chairperson will be appointed in consultation with the DMS & CEO of the Hospital.

New membership/change in members will be granted based on requirements. These will be through nomination, selection by members of the committee, and as included in the respective minutes of the meeting.

The committee members are appointed in consultation with the Chairperson, DMS & CEO.

 

Jurisdiction:

Within the organization the Blood Transfusion Committee decisions are final

The committee reporting follows the standard format provided by the Quality Department indicating the accomplishments, challenges, and improvement initiatives including education activities.

The report includes recommendations for executive leadership support.

Working as a multidisciplinary team, the committee may receive referrals or reports from other committees.

 

Evaluation:

The performance of the members of the Committee is evaluated in terms of their attendance and contribution to the overall objectives of the committee.

Annual evaluation of the Committee shall be done as per the below format

Amendment:

Amendments	Amendment Date	Revision No

Appropriate Approval

Prepared by:	Approved by:	Issued by:
Quality Team	Chief Executive Officer	Quality Manager