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Transfusion Audits


jhaig

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Any advice on how often transfusion audits should be performed? I try to do as many observations as possible, but being the only person in my department I find very little free time to actually stand over nurses while they administer a blood product. I also think that if they know I'm watching, compliance will be artificially high. Should I involve nursing in the process or just keep it to myself here in the blood bank?

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I do observations, my residents do observations, and I have formed a tight bond with Nursing QI to do observations. I use an in depth audit tool for audits performed by me or the blood bank residents. The Nursing audit tool is a little different. The nurses don't do a self evaluation- they have to get a QI rep to do the observation. They appear to be honest in their evaluations because I get reports with failures all the time.

I am at home, but if you would like me to send you my audit tools, drop me an email at my work 20 and I will send them to you. My hospital has blocked this site and I can now only access it from home.

Email: RCURRIE@swmail.sw.org

BC

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We have a 16-point checklist that the Med Techs use - it has been a good thing to involve the bench techs as it 1) helps develop them as future leaders and 2) helps build a bridge between the blood bank staff and the nursing staff.

We transfuse roughly 10,000 products per year in a 400-bed hospital. We audit about 30 transfusions a month; we do so many per floor/unit based on the average number of transfusions each unit does per year.

In fact, one of our AABB inspectors was so pleased with the tool they didn't even wish to see a transfuion while they were here.

I would be happy to share our checklist.

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We have a 16-point checklist that the Med Techs use - it has been a good thing to involve the bench techs as it 1) helps develop them as future leaders and 2) helps build a bridge between the blood bank staff and the nursing staff.

We transfuse roughly 10,000 products per year in a 400-bed hospital. We audit about 30 transfusions a month; we do so many per floor/unit based on the average number of transfusions each unit does per year.

In fact, one of our AABB inspectors was so pleased with the tool they didn't even wish to see a transfuion while they were here.

I would be happy to share our checklist.

Regina,

I would love to have a copy of your checklist. I'm a fairly new supervisor who took over after a 6-month lag between the former supervisor and my arrival. I'm still learning all of the processes and can use all the tools I can get.

Thanks!

Margaret Wilde

wildema@trinity-health.org

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We have an audit system in place. The audit should be checking from issue through transfusion to posting in patient's chart. This should also include checking for written physician's order and signed consent for transfusion in place before the transfusion began. I have all of the blood bank staff involved in doing audits as part of the annual competency.

My checklist encompasses each step from issue in blood bank to beside identification,

initial vitals taken before beginning. hanging unit (checking that nothing else is running in the line. Then I return approx 4 hrs later to verify completion, transfusion form completion and signed and posted in chart.

number of audits per year is based on 1% of the total transfusions in a year.

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We do audits on every nursing unit, OR, ER, Dialysis, and any other department that transfuses blood products. Sometimes it's hard to get to all of them because of time constraints, so I try to stick with the units that transfuse the majority of the products. I use the same worksheet for every unit, however.

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i to would like to see your checklist. i just was promoted to bb super at my facility and am by procedure, required to monitor each and every transfusion that occurs. what is the minimum audits required per 100 transfusions? are there guidlines that state this number specificaly? i am the only bb tech at a 250 bed hospital transfusing about 300 products a month...help please...thanks in advance my email is mrbull_777@yahoo.com

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We do audits on every nursing unit, OR, ER, Dialysis, and any other department that transfuses blood products. Sometimes it's hard to get to all of them because of time constraints, so I try to stick with the units that transfuse the majority of the products. I use the same worksheet for every unit, however.

I would suggest making an extra effort to audit those units that transfuse rarely such as peds and L&D. They are the ones most likely to have problems. Places like ICU where they transfuse every day have very few problems because they do it so often.

My biggest problem is the OR. They are special!!! They can't get anything right and I can get no support to get them to comply. The sad thing is, it will take a significant event to get their attention and even then they will shift the blame faster than a politician and accept no level of responsibility. Oh well such is our fate.

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Gee, I thought it was only MY O.R. that was high and mighty and so versed in the ways of transfusions that they don't feel the need to follow protocols!

Thanks for the tip. I do agree that crap rolls downhill and the lab is usually at the bottom. It's almost as if we have procedures in place not for the patient's protection, but for fending off attacks from other departments.

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We have a 16-point checklist that the Med Techs use - it has been a good thing to involve the bench techs as it 1) helps develop them as future leaders and 2) helps build a bridge between the blood bank staff and the nursing staff.

We transfuse roughly 10,000 products per year in a 400-bed hospital. We audit about 30 transfusions a month; we do so many per floor/unit based on the average number of transfusions each unit does per year.

In fact, one of our AABB inspectors was so pleased with the tool they didn't even wish to see a transfuion while they were here.

I would be happy to share our checklist.

Regina, I would love to have a copy of your checklist. Thanks, Kay Shaw

kay.shaw@triadhospitals.com

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We have a 16-point checklist that the Med Techs use - it has been a good thing to involve the bench techs as it 1) helps develop them as future leaders and 2) helps build a bridge between the blood bank staff and the nursing staff.

We transfuse roughly 10,000 products per year in a 400-bed hospital. We audit about 30 transfusions a month; we do so many per floor/unit based on the average number of transfusions each unit does per year.

In fact, one of our AABB inspectors was so pleased with the tool they didn't even wish to see a transfuion while they were here.

I would be happy to share our checklist.

I would like you have a copy of your checklist as well. Thanks.

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hi, i am interested in obtaining your check list, but actually i need some help with the formula to determine how many audits to perform monthly. (reference to standards?) i supervise a bloodbank in a 250 bed facility that transfuses somthing over 4000 units a year. furthermore, i am the only dayshift blood bank tech, so my time management has become an issue. i perform all the supervisor duties (inventory,blood utilization,trouble shooting,pm,all dayshift bench work...ect) it is a one man operation here. i am looking the streamline various procecdures, so i can work in a more efficent mannner without impacting patient safety. we are in tube testing ,but are looking to automate (im not holding my breath...lol) to ease the workflow. any ideas to shorten time spent on audits and utilization will be appreciated...thanks in advance. email is mrbull_777@yahoo.com

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