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West of Scotland Blood Centre Audit of Hospital Compliance with Traceability Arrangements for Cross‐Matched Blood
Author(s) -
Mathur K.,
Thomson A.,
Peterkin M.
Publication year - 2006
Publication title -
transfusion medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.471
H-Index - 59
eISSN - 1365-3148
pISSN - 0958-7578
DOI - 10.1111/j.1365-3148.2006.00693_51.x
Subject(s) - audit , receipt , traceability , medicine , blood transfusion , documentation , medical emergency , business , quality (philosophy) , emergency medicine , operations management , accounting , surgery , engineering , computer science , philosophy , epistemology , software engineering , programming language
Since 8 th November 2005, the Blood Transfusion Services in the UK have been governed by ‘The UK Blood Safety and Quality Regulations 2005’. The Secretary of State for Health, the Competent Authority, can authorise, suspend, or revoke the licence of a Blood Establishment if its activities are not found safe for the purpose of transfusion. The UK Law requires Blood Establishments to establish, and maintain, a quality system based on the Principles of Good Practice (Regulations 6–8). Regulation 8 demands a system for unambiguous vein‐to‐vein traceability and retention and accessibility of traceability data for a minimum period of 30 years. This Blood Centre regularly meets demands to supply cross‐matched blood for patients with multiple irregular allo/auto‐antibodies. To comply with the traceability requirements, we devised a manual system of documentation, a ‘Transfer Receipt’ form, to record the safe supply of cross‐matched blood to Regional hospitals. Audit Design Relevant hospital staff were prospectively educated to witness and document the safe and appropriate receipt of blood issues in the bottom section of the accompanying transfer receipt. The completed transfer receipts were returned to the BTC as proof of supply of these components. We audited the completeness of returns of these transfer receipts for a period of 3 months ‐ December 2005–February 2006. Results A total of 311 issues of cross‐matched blood were supplied to 21 Regional hospitals during the audit period, with 2/3 rd of them (235) involving 10 hospitals, each of which received cross‐matched blood at least once per week. Total returns was 64% (199) and 31% of the returned transfer receipts were incompletely documented. Time of receipt was not recorded on 65% of forms and 21% failed to document the condition of the blood when received. In addition, 16% of receipts were not witnessed and a further 16% were returned with no information. The integrity of blood packs was not documented on a further 3% of transfer receipts. Although completeness of receipts improved during the audit period, the return rate of transfer receipts did not, being 68%, 58%, and 66% in months 1, 2, and 3 respectively. Conclusion This audit raises issues about compliance with the UK Blood Safety Law and suggests a need for staff education to ensure that the Law is not breached.