hosp_standards_bloodbank.pdf

7/23/2019 Hosp_Standards_BloodBank.pdf

1/15

Hospital Standards for Accreditation for Afghanistan

Section 4: Ancillary and Support Services

Blood Bank


2/15

Hospital Standards for Accreditation for Afghanistan:

Assessment of Progress in Achieving the Standards

Hospital Department or Area: Blood Bank

Hospital Facility: __________________________________________

Assessor: __________________________________________ Date of assessment: ____________________

Blood Bank

Standard

NumberStandard

Criteria for Verification of Meeting

Standard

Compliance in

Meeting Standard(Score)

Basis for Evaluation Grade/

Comments/Action Plan

Full

2

Partial

1

None

0

(Circle appropriate score)

1 Verify the following exist and are functioning

or operable:

A working washbasin with faucet

2 1 0

Table with flat and washable surfaces 2 1 0

Good lighting 2 1 0

Good ventilation 2 1 0

Blood bank facility

and equipment is

appropriate:The

blood banks facilities,

equipment, and

furniture are proper and

functioning

A private area to care for blood donor

interviews2 1 0

A stretcher for phlebotomy procedures 2 1 0

Files for record keeping 2 1 0

Centrifuge 2 1 0

Scale for donor 2 1 0

There is a sink with running water for

instrument cleanup area 2 1 0

Section 4: Ancillary and Support Services. Blood Bank

Hospital Standards ManualAfghanistan 2 of 15


3/15

Blood Bank

Standard

NumberStandard


Standard

Compliance inMeeting Standard(Score)

Basis for Evaluation Grade/Comments/Action Plan

Full

2

Partial

1

None

0


There are containers with 0.5% chlorine

solution in the procedure areas

2 1 0

There are puncture-resistant containers for

disposing of sharps in the procedure areas2 1 0

There are containers with leak proof

plastic bags to dispose of medical waste in

the procedure areas.

2 1 0

There are containers for general waste in

office areas.2 1 0

2 Cleanliness of the

blood bank: The blood

bank is clean

Verify whether the following areas and

equipment of the blood bank are free of

blood, stool, spills, urine, sputum, dust, dirt,

trash, and insects:

Floors

2 1 0

Walls 2 1 0

Ceilings 2 1 0

Working bench 2 1 0 Refrigerators 2 1 0

Bleeding couches 2 1 0

Countertops/surfaces 2 1 0

Chairs 2 1 0

Wash-up room 2 1 0

Toilets 2 1 0

3 Safety: General bio- Verify whether: 2 1 0




4/15

Blood Bank

Standard

NumberStandard


Standard



Full

2

Partial

1

None

0


Staff donot eat, drink or smoke in the

blood bank.

safety and prevention

practices are followed

in the blood bank Food and beverages are not stored in

refrigerators used for storing blood or

blood products.

2 1 0

4 Proper use of

antiseptics: The

concentration and use

of antiseptics (for skin

or mucous membranepreparation) are

according to proper

practice standards

Verify whether:

The antiseptic concentration is labeled

with the name and concentration of the

antiseptic as follows:

o

Ethyl, isopropyl alcohol ormethylated spirit (60%90%), or

o Cetrimide and chlorexidine gluconate

(2%4%) (e.g., Savlon), or

o Chlorexidine gluconate (2%4%)

(e.g., Hibiclens, Hibiscrub,

Hibitane), or

o

Iodine preparations (1%3%) (e.g.,Lugols), or

o Iodophor (1:2500) (e.g., Betadine)

2 1 0

Antiseptics are prepared in small, reusable

containers for daily use2 1 0

The reusable containers are thoroughly

washed with soap and water, rinsed with

clean water and dried before refilling.

2 1 0

Reusable containers are labeled with date 2 1 0




5/15

Blood Bank

Standard

NumberStandard


Standard



Full

2

Partial

1

None

0


each time they are refilled.

Gauze or cotton wool is stored in drycontainers without an antiseptic. 2 1 0

Instruments and other items are stored in

dry containers without antiseptics.2 1 0

Pick up forceps are stored in dry

containers without antiseptics.2 1 0

5 Proper

decontamination:The

decontamination ofinstruments and other

articles (immediately

after use and before

cleaning) is performed

according to the

standards.

Verify whether:

The concentration of chlorine solution is

0.5%:Liquid chlorine:

o If using a concentration of 3.5%, 1

part bleach for 6 parts water, or

o If using a concentration of 5%, 1 part

bleach to 9 parts water, or

o If using another concentration uses the

following formula to prepare thesolution: TP of water =

[%concentrate/0.5%] 1 for one part

of chlorine

- Powder chlorine:

o If using Calcium hypochlorite (35%),

14 grams bleach powder for 1 liter

water, or

o

If using Calcium hypochlorite (70%),

2 1 0




6/15

Blood Bank

Standard

NumberStandard


Standard



Full

2

Partial

1

None

0


7 grams bleach powder for 1 liter

water

A new chlorine solution is prepared at the

beginning of each day or sooner if needed2 1 0

Plastic containers are used for

decontamination2 1 0

Instruments and other items are soaked in

the 0.5% chlorine solution for 10 minutes.2 1 0

After 10-30 minutes, instruments and

other items are removed from the chlorinesolution and rinsed with clean water or

cleaned immediately.

2 1 0

Blood Takingstandards 6-11 must be observed in sequence with the same patient

6 Blood taking: The

provider prepares for

blood taking.

Observe during two blood taking procedures

if the healthcare worker:

Prepares necessary equipment and

supplies

2 1 0

Explains the procedure to the patient 2 1 0

7 Blood taking: Hand

hygiene is performed

before blood taking.

Verify whether staff perform hand hygiene

before the procedure:

Washes hands with running water and

soap for 1015 seconds and dries with an

individual clean towel, paper towel or

allow hands to air dry, or

Rubs hands with 35 ml of an alcohol-

2 1 0




7/15

Blood Bank

Standard

NumberStandard


Standard



Full

2

Partial

1

None

0


based solution until the hands are dry (if

hands are not visibly soiled)

8 Verify whether:

Identifies the best veins for inserting the

IV needle

2 1 0

Blood taking: The

provider prepares the

puncture site according

to the standards. Positions the arm with support 2 1 0

Puts the tourniquet on the upper arm about

9 cm (34 inches) above the antecubital

space to confirm that the vein is visible

and then release the tourniquet.

2 1 0

Palpates and locate puncture site 2 1 0

Using a fresh cotton swab cleans the site

with 6090% alcohol, in a circular motion

starting at the center.

2 1 0

If the venipuncture site is visibly soiled,

first washes it with soap and clean water

and dry with a clean cloth.

2 1 0

Allows drying. 2 1 0

9 Verify the existence of:

Puts the tourniquet on the upper arm again2 1 0

Blood taking: The

provider collects blood

using IP practices. Puts sterile or high-level disinfected

gloves on both hands2 1 0

Inserts the hypodermic needle into the

vein without touching the skin if possible.

2 1 0




8/15

Blood Bank

Standard

NumberStandard


Standard



Full

2

Partial

1

None

0


Releases the tourniquet 2 1 0

Secures the needle by placing a piece oftape across the blood collection tubing 2 1 0

Collects blood in appropriate specimen

tubes.2 1 0

Collects the blood using a blood

collection set with a closed system

consisting

2 1 0

When the required amount of blood has

been obtained, removes the needlewithout touching the barrel or tip of the

needle

2 1 0

Covers the insertion site with a gauze

square or cotton wool2 1 0

Applies pressure until the bleeding stops

or asks donor to do it2 1 0

Secures the gauze squares or cotton woolwith surgical tape after bleeding stopped.

2 1 0

10 Blood taking:

Instruments and

medical waste are

disposed after blood

taking.

Verify whether:

If needle and syringes are used,

decontaminates the syringe by flushing it

three times with 0.5% chlorine solution

and disposes in a container with a

puncture proof container.

2 1 0

Places the needle/sharps in a puncture- 2 1 0




9/15

Blood Bank

Standard

NumberStandard


Standard



Full

2

Partial

1

None

0


resistant sharps container.

Disposes of other medical waste (e.g.,

cotton wool) in a container with a leak

proof plastic bag.

2 1 0

Places tubes and other equipment in a

0.5% chlorine solution for 10-30 minutes.2 1 0

Removes gloves, after immersing in a

0.5% chlorine solution, and places them in

a container with a leak proof plastic bag.

2 1 0

11 Blood taking: Handhygiene is performed

after blood taking

Verify whether hand hygiene is performedafter removing the gloves:

Washes hands with running water and

soap for 1015 seconds and dries with an

individual clean towel, paper towel or

allows hands to air-dry, or

Rubs hands with 35 ml of an alcohol-

based solution until the hands are dry (ifhands are not visibly soiled)

2 1 0

12 Verify through interviews and records review

if the following tests are performed:

Blood typing (ABO)

2 1 0

Rh Factor (anti-D reagent) 2 1 0

Blood safety: The

blood component and

infectious disease testing

is performed according to

the standards. HIV-1 2 1 0

HIV-22 1 0

Hepatitis B (HBsAg and anti-HBc) 2 1 0




10/15

Blood Bank

Standard

NumberStandard


Standard



Full

2

Partial

1

None

0


Hepatitis C (anti-HCV) 2 1 0

Syphilis with RPR or VDRL2 1 0

Records the results of tests in a printed

register2 1 0

13 Verify if:

Fresh blood units of fresh are kept

between 28oC

2 1 0

Blood safety: Blood

storage is performed

according to the

standards Frozen fresh plasma between -20 and -

40oC2 1 0

Frozen fresh plasma between -20 and -

40oC2 1 0

Frozen fresh plasma are kept within the

expiration date (up to 1 year)2 1 0

The temperature is monitored and

recorded2 1 0

The fresh blood units that are out of the

parameters are discarded (without theexpiration date or kept out of refrigeration

longer than 2 hours)

2 1 0

The frozen fresh plasma units that are out

of the parameters are discarded (without

the expiration date or kept out of

refrigeration longer than 4 hours)

2 1 0

There is a person per shift assigned to 2 1 0




11/15

Blood Bank

Standard

NumberStandard


Standard



Full

2

Partial

1

None

0


monitor the blood storage

14 Verify if the recipient blood was tested for the

following:

Blood typing (ABO)

2 1 0

Rh Factor 2 1 0

Blood safety: The pre-

transfusion testing and

cross matching is

performed according to

the standards. Compatibility between selected samples

of donor blood with the recipients blood

(cross-matching).

2 1 0

15 Blood safety: The

blood identification isperformed according to

the standards.

Verify if the blood and blood products are

identified as follows: Tagged with donors information:

o Blood typing (ABO)

o Rh Factor

o Results of HIV, Siflis, HBV and HCV

tests

o Date blood was drawn

o

Number of blood bag and number ofdonor

o Blood unit expiration date

o Signature of the responsible person

2 1 0

Tagged with recipients information:

o Name of recipient

o Ward, bed number

o Blood typing (ABO)

o

Rh Factor

2 1 0




12/15

Blood Bank

Standard

NumberStandard


Standard



Full

2

Partial

1

None

0


o Number of blood bag and number of

donor

o

Number of units needed for

transfusion

o Donors blood typing (ABO)

o Donors Rh Factor

o Date of transfusion

o Signature of the responsible person


process of cleaninginstruments and other

items is performed

according to the

standards.

Verify by observation if the person cleaning

the instruments complies with the followingsteps and recommendations:

Wears:

o Utility gloves

o Mask and eyewear protection orface

shield

o Plastic apron

o Gumboots or enclosed shoes

2 1 0

Utilizes:

o Soft brush

o Detergent (liquid or powder)

2 1 0

Scrubs instruments and other items under

the surface of water, completely removing

all blood and other foreign matter.

2 1 0

Disassembles instruments and other items

with multiples parts and cleans in the2 1 0




13/15

Blood Bank

Standard

NumberStandard


Standard

Compliance in



Full

2

Partial

1

None

0


grooves, teeth and joints with a brush.

Rinses the instruments and other items

thoroughly with clean water. 2 1 0

Allows instruments and other items to air-

dry, or dries with a clean towel.2 1 0

Washes hands after removing gloves:

o Washes hands with running water and

soap for 1015 seconds and dry with

an individual clean towel, paper towel

or allows hands to air-dry, oro Rubs hands with 35 ml of an alcohol-

based solution until the hands are dry

(if hands are not visibly soiled)

2 1 0

17 Verify if the disinfectant cleaning solution is

prepared as following:

A 0.5% chlorine solution is prepared.

2 1 0

Blood safety: The

preparation of a

disinfectant cleaning

solution is performed

according to the

standards

Detergent that does not contain an acid,ammonia or ammonium is added to the

0.5% chlorine solution until a mild soapy

cleaning solution is made.

2 1 0


cleaning equipment is

decontaminated,

cleaned and dried

before reuse or storage

Verify by observation if the mops, buckets,

brushes and cleaning cloths are:

Decontaminated by soaking for at least 10

minutes in 0.5% chlorine solution or other

approved disinfectant after use..

2 1 0




14/15

Blood Bank

Standard

NumberStandard


Standard

Compliance in



Full

2

Partial

1

None

0


Washed in detergent and water after use. 2 1 0according to the

standards Rinsed in clean water. 2 1 0

Dried completely before reuse or storage. 2 1 0

19 Verify by observation if:

Medical waste is placed in a washable

container with a leak proof plastic bag.

2 1 0

Medical waste containers are closed and

collected when three quarters full.2 1 0

Medical waste and

sharps are properly

disposed of: The

collection of medical

waste is performed

according to the

standards

Sharps are placed in a puncture-resistant

container (heavy card box, containersmade of hard plastic, metal container with

small opening).

2 1 0

Sharps disposal containers are closed and

collected when three quarters full.2 1 0




15/15

Row Scoring compliance with the standards

A Total Score (sum total checks for full, partial and no compliance)B Score for each category (Full compliance =2, Partial compliance =1 and

Non-compliance =0) 2 1 0

C Score of Full, Partial and Non-compliance (Multiply Row A times

Row B)

D TOTAL: Sum of scores for Full, Partial and Non-compliance(Add all

three columns in Row C)

E Score possible (Total criteria times 2less any N/A) 166

F Percentage Compliance with these standards (Divide Row D by Row E) %

Total criteria 83 x 2 pts =maximum 166 point s

possible (less any N/A)



hosp_standards_bloodbank.pdf

Documents