84-15 Transfusion and isoimmunization committee.

(A)  The transfusion and isoimmunization committee shall be appointed pursuant to these bylaws and include representation from physicians of the clinical departments frequently using blood products, nursing, transfusion service, and hospital administration. The majority of members shall be members of the medical staff. The committee shall meet at least quarterly and carry out the following duties:

(1)  Evaluate the appropriateness of all transfusions, including the use of whole blood and blood components.

(2)  Evaluate all confirmed or suspected transfusion reactions.

(3)  Develop and recommend to the medical staff administrative committee policies and procedures relating to the distribution, use, handling, and administration of blood and blood components.

(4)  Review the adequacy of transfusion services to meet the needs of patients.

(5)  Review ordering practices for blood and blood products.

(6)  Provide a liaison between the clinical departments, nursing services, hospital administration, and the transfusion service.

(7)  Use clinically valid criteria for screening and more intensive evaluation of known or suspected problems in blood usage.

(8)  Keep written records of meetings, conclusions, recommendations, and actions taken, and the results of actions taken, and make these available to each committee member and to the medical staff administrative committee.

(B)  Each member of the medical staff shall conform to the policies established by the transfusion and isoimmunization committee, including the following:

(1)  All pregnant patients admitted for delivery or abortion shall be tested for Rh antigen.

(2)  No medication may be added to blood or blood products.

(Board approval dates: 4/7/2000, 9/6/2002, 6/4/2004, 4/6/2016)