Key findings from 2005 Re-audit of Bedside Transfusion Practice

1
Key findings from 2005 Re-audit of Bedside
Transfusion Practice
In 2005 the NBS repeated an audit of the
administration of red blood cells, based on 1999
guidelines from British Committee for Standards
in Haematology. These slides illustrate the key
points from the audit findings.

• Organisational Aspects
• Organisational Audit showed 2 of hospitals do
  not have have a Hospital Transfusion Committee
• 10 do not have a Hospital Transfusion Team and
  25 do not have a Transfusion Practitioner. In
  10 there is no Lead Consultant for Transfusion.
• 56 of hospitals provide induction transfusion
  training and 39 provide annual update training
  for 50 or more of nurses
• Care of the Elderly and General Medicine are two
  disciplines noted to not regularly attend
  Hospital Transfusion Committee meetings
• 20 of hospitals have not undertaken regional and
  local transfusion audits
• 3 of hospitals do not formally review critical
  incidents involving blood transfusion and 17 do
  not contribute data to the SHOT reporting scheme

2
Key findings from 2005 Re-audit of Bedside
Transfusion Practice
269 NHS and independent hospital sent transfusion
data on 8054 cases from England, Scotland and
Wales

• Administration Practice
• 6 of transfused patients were not wearing a
  wristband for their transfusion
• 9 did not have the identifiers (Surname, First
  Name, Date of Birth ID number) required by
  guidelines
• Date of transfusion was unrecorded in 5 of cases
  audit, and start time was unrecorded in 3.
• 9 of patients had no vital signs recorded before
  the transfusion started
• 15 of patients had no observations taken during
  the transfusion
• 22 of patients had no observations after the
  transfusion finished
• Comment
• Some transfused patients are at risk because
  they are unidentifiable and could experience
  unobserved transfusion reactions