PF809 ARE NATIONAL GUIDELINES AND MANDATORY TRAINING ENOUGH TO ENSURE SAFE TRANSFUSION PRACTICE?

Background: Errors in administering blood product represent a risk for patient safety. The British Society of Haematology (BSH) published guidelines to promote safe transfusion practice (1). These guidelines states that should be recorded: the unique component donation number and the date, start time and the identification of the person administering the component.The guideline also sets the standard for monitoring the patient during the transfusion with pulse, temperature, respiratory rate and blood pressure at the start of the transfusion, after 15 minutes of the start and within one hour from the end. Transfusion training is mandatory for all health professionals involved in transfusion practice. Aims: The aim of this study was to establish if the guidelines established by BSH are applied in clinical practice across different departments. Methods: We performed a retrospective audit on transfusion documentation and patient monitoring and in a district general hospital. We included transfusion of red packed cells, platelets and fresh frozen plasma. Results: We identified 160 unit transfused (132 RPC, 16 PLTS and 12 FFP). Documentation of donation number and the date, start time and the identification of the person administering the component were complete in 88% of the cases, in 8% of the cases there was no documentation at all (Figure 1A); of the remaining in 80% of the cases was missing the signature of the administering person. Regarding the monitoring of the patient only 25% of the unit transfusions were monitored according to the guidelines, in 33% of the cases there was no documentation of the patient monitoring. The least monitored parameter was respiratory rate; the most frequent missed monitoring point was the one at the end of the transfusion (Figure 1B). Summary/Conclusion: Despite clear guidelines and compulsory training transfusion practice is still poor with more than a tenth of the transfusion being not fully documented in the notes and the number of transfusion episodes lacking adequate patient monitoring information outnumbering the transfusion monitored according to the guidelines (33% vs 25%).Performing an audit across the entire hospital allowed us to identify the departments where transfusion procedures were not applied systematically with the plan to offer target training and re‐audit to improve transfusion practice.