This section will briefly review standards related to training and competency assessment and will discuss strategies for facilitating competency assessment in small dispensary-only facilities. A full discussion of training and competency assessment is beyond the scope of this case.



Training and competency assessment are integral components of a quality system. Blood safety standards require that the TS

  • establish training policies and procedures (CSTM A3.2.1; CSA
  • develop and maintain a formal competency assessment program for staff involved in any transfusion-related activity (CSTM A3.2.3; CSA
  • participate in a recognized external proficiency testing program (CSTM A4.3.2; CSA

The tasks involved are huge in scope and include:

  • Training all technical, clerical, and clinical staff involved in transfusion
  • Developing formal competency assessment programs
  • Participating in proficiency testing programs
  • Performing regular audits of transfusion processes to identify systemic problems

Significant investment of financial and human resources are required and the challenges are exacerbated when attempting to maintain competency in dispensary-only facilities.

Competency Assessment

Historically, competency assessment within health facilities has been applied to all health professions except physicians. The justification has been that no further assessment of physician skills or documentation of competence is required as physician competency for tasks within the scope of the practice of medicine is handled via the medical staff credentialing process.9,10

Regardless of the type of staff, competency assessment programs should assess

  • all testing phases (pre-analytic, analytic, and post-analytic)
  • general knowledge applicable to multiple processes (e.g., safety, computer, standards)
  • multiple types of job-specific knowledge and skills (technical, clerical, clinical)
  • communication skills
  • problem solving skills
  • judgment and decision making

Typically, competency assessment includes a combination methods 7 such as:

  • directly observing job performance

  • reviewing records (patient chart entries, test results, preventative maintenance, quality control)

  • evaluating results of written assessments (quizzes or case studies that use clear, objective questions)

  • assessing performance on proficiency testing kits (in which materials have been split for this purpose)

Facilitating Competency Assessment

Several strategies exist for facilitating transfusion-related training and competency assessment in small satellite facilities, including ones with dispensary-only laboratories. Possible strategies include using

Transfusion Safety Officers

One initiative that shows promise is the use of dedicated staff with specific responsibilities for transfusion safety, for example, using transfusion safety officers (TSO), whose responsibility extends throughout a health region. In general, TSOs are responsible for the quality and safety of transfusion within their respective institutions,particularly in the transfusion service and transfusing units, wards or clinics. See sample job descriptions of Canada's TSOs.

TSOs facilitate training and competency assessment since they constitute a dedicated staff position responsible for transfusion safety from both technical and clinical perspectives. Adding such responsibilities to existing staff such as laboratory supervisors and managers has difficulties due to their already heavy workloads.

Creating dedicated staff positions requires funding and business cases are needed to justify the cost.

Several countries have implemented TSO positions to varying degrees. Some have limited the TSO position to nurses and others employ both nurses and medical laboratory technologists/scientists.

In Canada, for example, the province of Quebec has both a TSO nurse and a TSO technologist associated with each of its approximately 24 designated transfusion centres. In other provinces only a few regions have implemented TSOs to-date. Canada's TSOs, along with other transfusion professionals, have formed an informal group with a bilingual website and mailing list, the latter limited to Canadians.

In the UK, Australia, and New Zealand, the TSO role has focused more on nurses, who may be called TSOs, transfusion nurses, transfusion specialists, specialist practitioners of transfusion (SPOT), and more.

Boulton briefly discusses the issue of nurses versus medical technologists and other health professionals for the TSO role. 1 Gray and Melchers discuss the roles and responsibilities of transfusion nurse specialists in the UK.11

Transfusion Nurses

Like TSOs, transfusion nurses are a relatively new development.Transfusion nurses focus on transfusion safety outside the laboratory and provide education, training, audits, data gathering and analysis, coordination, etc.

UK. In 2002 there were 50 such nurses in the 413 UK hospitals eligible to take part in the SHOT scheme and most require further training in transfusion to perform the job.1 Scotland also instituted transfusion nurse specialists 2 and the SNBTS Better Blood Transfusion training program on safe blood administration.3

Australia has also developed the transfusion nurse role, including extensive an education program.

  • Towards Better, Safer Blood Transfusion provides an excellent overview of international developments, including Canada.4

An excerpt about the Australian experience4 :

The assessment of the implementation of the transfusion nurse role into participant hospitals was overwhelmingly positive. Most centres rated the availability of the specialist nurse as the critical success factor for their program of transfusion practice improvement endeavours. This view is repeated wherever transfusion nurses have been embraced in Australia.

Canada. As noted, in Canada Quebec has an extensive network of nurse TSOs. Ontario has the Ontario Nurse Transfusion Coordinators ( ONTraC ) program, which includes a blood conservation mandate. The BC Provincial Blood Coordinating Office ( PBCO ) has also been active:

New Zealand. The NZBS has appointed six Transfusion Nurse Specialists, who are responsible for education and training within the health regions and also assist with incident management and clinical audit. Thetransfusion nurses have proved to be extremely successful in assisting clinicians to use blood and blood products effectively and efficiently.8


Whether TSOs or transfusion nurses, dedicated staff with specific responsibilities for transfusion safety can play a key role in education and competency assessment, especiallyfor smaller satellite sites who oftenlack access to TM expertise. As recommended in the 2003 UK SHOT Report 6:

Audit and feedback at local level can also be effective in improving practice and, together with education and training, is a key role of the SPOT [Specialist practitioners of transfusion]. HTTs [hospital transfusion teams] and SPOTs must now be established in all trusts.

The HTT requires clinical leadership ideally from a consultant haematologist, with dedicated sessions, supported by a SPOT (nurse, BMS or medical professional) and the blood bank manager.

BMS = biomedical scientist, the UK term for a medical laboratory technologist/scientist

Proficiency Testing Paper Challenges

Proficiency testing, now known by the sexier name, external quality assessment (EQA), involves assessing laboratory performance by an outside agency, which typically distributes "wet" specimens to similar laboratories and compares test results to those obtained by one or more referee laboratories. (You didn't know that blood bank case studies were X-rated, did you?Okay, I'll stop being silly!)

Note: Proficiency testing (EQA) is not competency assessment:

  • Proficiency testing assesses if a laboratory (as a whole) is competent to perform a test.
  • Competency assessment assesses if each individual who performs a test or process is competent to perform it.

EQA has been difficult for non-testing laboratories, such as those that only store and issue blood products (dispensaries). One strategy has been paper challenges, such as those administered by the Alberta Laboratory Quality Enhancement Program (ALQEP) for Level D (non-testing) laboratories.

ALQEP currently issues 3 paper challenges/year involving for >80 dispensary-only laboratories in four Canadian provinces. A portion of a typical case study challenge (reproduced with permission):

Your laboratory receives a call that two patients are being transported to your facility from a motor vehicle accident. The physician in emergency orders two units of red blood cells (RBCs) for each patient stat. You will not have time to order and receive blood prior to arrival of the patients.

Current RBC inventory:

  • 2 - O Rh(D) Negative uncrossmatched
  • 2 - O Rh(D) Positive crossmatched for a patient who is scheduled for elective surgery in 3 days
  • 2 - A Rh(D) Positive crossmatched for a patient who has undergone surgery and has been discharged from the facility

Patient One - Donald Jones, a 32 year old male. You have no record of previous transfusions for this patient in your facility.
Patient Two - Mary Jones, a 27 year old female. Your blood bank log book shows that she received two units of blood after a postpartum hemorrhage one year ago.The records indicate that she is A Rh(D) Positive.

1. Which two units would you issue for:

Patient One - Donald Jones:
Patient Two - Mary Jones:


2. What requests would you make prior to releasing the units chosen in #1 above?

  • Collect pre-transfusion blood samples from both patients
  • Physician authorization
  • Recipient consent, if possible

When time permits:

  • Order 2 replacement crossmatched RBCs for elective surgery patient
  • Order replacement of emergency O Rh(D) negative stock

As shown, carefully constructed paper challenges are capable of assessing critical decision-making skills required by generalists working in small facilities with limited access to TM expertise. As Howanitz et al.7 conclude:

From our own experiences about employee competence assessments, communication and judgment and analytical decision making are essential skills that rarely are evaluated. When evaluated, we recommend written testing, since the intrepretation [sic] of these skills using direct observation is highly subjective.

This Case

The dispensary laboratory in this case study had inadequate TM support, in thatSOPs, training and competency assessment in transfusion responsibilities were not provided for generalist staff. Some of the key deficiencies included:

  • A region-wide quality system had not been implemented.
  • Although a procedure manual existed, it had not been regularly updated and staff had begun to perform some tasks based on word-of-mouth from existing staff to new staff rather than follow the outdated manual.
  • Facility-specific SOPs for key transfusion tasks were lacking (see Discussion - Part 4)
  • Formal training and competency assessment programs did not exist for transfusion-related (and other) duties.

These deficiencies contributed to staff transfusing the wrong ABO group and resulting patient death.

The central TS and its medical director were responsible for providing adequate TM support to all satellite laboratories. Transfusion support is especially critical to small dispensary-only laboratories that often lack on-site technical, nursing, and medical expertise in TM. Without ongoing education and training, generalist staff may not even be aware of the life-threatening risks involved in various transfusion policies and procedures.

As discussed, with the advent of blood safety standards targetted to hospital transfusion services being relatively new in Canada and elsewhere, health regions are working to improve transfusion safety but 100% compliance with all requirements of the new standards, especially in small facilities, has not yet been reached.

Learning Points

  • Training and competency assessment are required by blood safety standards as part of a quality system that protects patient safety.
  • Providing TM support to small satellite facilities involves working with on-site staff to develop and maintain procedures, policies and processes, including provision of training and competency assessment.
  • Without adequate staff training and competency assessment, patient safety is at risk.
  • Despite shared responsibilities, the medical director is ultimately responsible for all medical and technical policies and procedures in the TS.
  • When systems fail, there are often multiple contributory causes.

Practical Notes

  • Obtaining funding for new staff positions requires developing business plans. Examples that can be used as templates and modified appropriately:
  • Paper challenges have several applications. They can assess the
    • decision-making skills required by generalists working in small facilities and identify systemic (facility-and region-wide) deficiencies
    • competency of individuals, if used as one component of an overall competency assessment program
  • For maximum effectiveness, case studies used as paper challenges should be
    • reality-based
    • tailored to specific facility circumstances, if possible
    • use objective questions

*If you have comments on this section, please contact Pat: This email address is being protected from spambots. You need JavaScript enabled to view it.

TraQ self study questions

1. Which type of staff need to be trained and undergo competency assessment in a TS?


2. Differentiate between proficiency testing and competency assessment.


3. Why do TSO and transfusion nurses facilitate competency assessment in satellite facilities?


4. List 3 characteristics of paper challenge case studies needed for them to be effective.


More Discussion...

  • Part 1: Use of historical blood groups
  • Part 2. Issuing blood to the OR
  • Part 3. Medical consultation
  • Part 4: Transfusion-related responsibilities
  • Part 5: Training and competency assessment <--You are here

**Proceed to Case Summary

Further Reading


1. Boulton F. The ?hospital transfusion practitioner". Blood Matters 2002 May.

2. Scottish National Blood Transfusion Service. Quality improvement programme: safe and effective transfusion in Scottish hospitals ? the role of the transfusion nurse specialist (SAET Study). April 2004

3. SNBTS. Better Blood Transfusion

4. Govt. of Australia. Towards better, safer blood transfusion? A report for the Australian Council for Safety and Quality in Health Care, Commonwealth of Australia 2005.

5. Feenstra S. Role of a transfusion nurse. Blood Matters 2003 July;5(3):1?3.

6. 2003 UK SHOT Report

7. Howanitz PJ, Valenstein PN, Fine G. Employee competence and performance-based assessment. A College of American Pathologists Q-Probes study of laboratory personnel in 522 institutions. Arch Pathol Lab Med 1999;124(2):195?202.

8. NZBS. Statement of Intent. 1 July 2005 ? 30 June 2006.

9. JCAHO. Physician competency for waived & P.P.M.P. testing

10. CAP. Physician performed testing

11. Gray A, Melchers R. Transfusion nurses. The way forward. In: 2000?2001 SHOT Report.

Additional online resources

College of Physicians & Surgeons of Alberta. ALQEP TM program guide

BC Provincial Blood Coordinating Office:PBCO

PBCO: Clinical Transfusion Resource Manual |Safe Transfusion Practice Video and CD

Ontario Nurse Transfusion Coordinators: ONTraC