BLOOD / BLOOD COMPONENT TRANSFUSION

NNA : E5 .4

Blood and blood components are viewed as medication / treatment. All patients undergoing blood / blood component transfusions are subjected to potential risks. Any compromise in the quality of management will cause harm to the patient and predisposes the organization to litigations.2. Purpose [Why Audit] NNA : E5 .4

3. Objective

To ensure safe administration of blood / blood components.

To detect reactions related to blood / blood component transfusion. NNA : E5 .4

4. Standard All patients receive blood / blood component as prescribed. NNA : E5 .4

Criteria [What Can We Audit] Structure

Process

Outcome - the result for the patient NNA : E5 .4

Structure : Each patient has current legal written prescription.

Each patient has GXM request form.

NNA : E5 .4

Structure : There is a written Transfusion Practice Guidelines, Ministry of Health 2001 There is a written Standard Operating Procedure for Transfusion Practice. Nurse has knowledge and skill in transfusion practice.

NNA : E5 .4

Structure : Nurse has knowledge of transfusion reactions and its measures.

Nurse has knowledge of transfusion reactions and its measures.

Blood transfusion set NNA : E5 .4

Process Confirm doctors order.

Verify right patient with blood / blood component. NNA : E5 .4

Process [cont] Verify blood / blood component with GXM request form.

Monitor vital signs.

Prime line with 0.9 Normal Saline.

NNA : E5 .4

Process [cont] Titrate flow rate. Observe for reactions and take appropriate measures.

Accurate documentation.

NNA : E5 .4

Outcome Patient receives the correct blood / blood component.

Early detection of reactions and appropriate measures taken.

Proper documentation. NNA : E5 .4

6. Audit Guide6.1Inclusion criteria6.2Exclusion criteria

NNA : E5 .4

6. Audit Guide [cont]6.3Instrument6.4Methodology7.Definition of terms NNA : E5 .4

6.1. Inclusion Criteria All adult patients who are on blood / blood component transfusion. NNA : E5 .4

6.2. Exclusion Criteria Administration of Factor VIII / IX NNA : E5 .4

6.3. Audit Guide : Instrument Audit form (E5 AF 5.4) one audit form for one observation. NNA : E5 .4

6.4 Methodology

6.4.1Direct observation of blood / blood component transfusion and also gathering information from documents.

6.4.2Setting : All adult wards and day care unit.

NNA : E5 .4

6.4.3Population : Staff Nurses

6.4.4Sample Design-Random sampling NNA : E5 .4

6.4.5Sample Size-20 transfusions, 18 from any adult ward and 2 from day care.6.5Time Frame-1 month NNA : E5 .4

7. Definition of Terms 7.1.Written prescription any legal orders of blood / blood component transfusion must be endorsed in the patients case notes.

NNA : E5 .4

7.2.Time limit for transfusion :7.2.1blood / blood component must be transfused within 30 minutes of removing the pack from refrigeration. 7.2.2to start transfusion at 10 drops per minute. Nurse is to be at the patients bedside and to observe the patient for the first 15 minutes. NNA : E5 .4

7.2.3appropriate time frame per packi]whole blood : within 4 hoursii]packed cells : within 4 hoursiii]fresh frozen plasma : within 30 minutesiv]cryoprecipitate : within 30 minutesv]platelet concentrate : within 30 minutes NNA : E5 .4

7.3.Verify right patient with the blood / blood component - cross-check the patients case notes at the bedside in the presence of patient with GXM request form, blood card and the blood / blood component supplied. NNA : E5 .4

7.3.1confirm patient identification : ask patient his name / check bracelet7.3.2verify prescription : check doctors order in patients case notes

NNA : E5 .4

7.3.3verify accuracy of blood to be transfused together with the doctor by cross-checking blood pack / blood components against particulars in patients case notes with blood group and cross match form to confirm i] correct blood / blood component for the patient NNA : E5 .4

ii]correct blood / blood component for the patient

iii] ABO grouping & Rhesus factor correspond iv]screening for HbsAg, HIV and VDRL donev]blood not expired

* No. [i] - [iv] to be verified together with the doctor NNA : E5 .4

7.4. Baseline and regular monitoring

7.4.1patients blood pressure, pulse, respiration and temperature before administration

7.4.2Initial monitoring 20 minutes upon commencement of blood transfusion and followed by hourly until completion

NNA : E5 .4

7.5.Reactions - e.g. chills, rigors, skin changes [rash], pyrexia, hypo / hypertension, respiratory distress, nausea and vomiting, renal shutdown [oliguria /anuria], abnormal bleeding [haematuria], anaphylaxis, pain [infusion site, chest pain, abdomen, loin]. NNA : E5 .4

7.6. Appropriate measures stop transfusion immediately, inform doctor urgently and document measures taken

NNA : E5 .4

7.7. Proper documentation :7.7.1blood card must be completed accurately7.7.2document in the intake-output chart / patients progress notes [date & time of transfusion, blood type, amount transfused]7.7.3any transfusion reactions and appropriate measures taken NNA : E5 .4

7.8. Transfusion errors include any of the following :7.8.1blood / blood component given not according to prescription7.8.2blood pack number / blood group / Rhesus Factor not corresponding to GXM request form

NNA : E5 .4

7.8.3 name / registration number / identity card number on GXM request form not corresponding to patients case notes7.8.4expired blood transfused

NNA : E5 .4

7.8.5did not confirm screening for HbsAg, HIV and VDRL or non-emergency transfusion7.8.6transfusion time not complying to appropriate time frame [for non-emergency cases]7.8.7 appropriate measures not taken when reactions / complications arise

NNA : E5 .4

7.8.8 baseline and regular monitoring of vital signs not done7.8.9inappropriate personnel [e.g. non-qualified staff] verifying blood7.8.10improper / incomplete documentation

* If any one of the errors above occur, it would be considered as transfusion error. NNA : E5 .4

NNA : E5 AF 5.4

NNA : E5 AF 5.4

NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIAVERSION 2/04ELEMENT 5 : CONTINUUM OF CARE

TOPIC : 5.4 BLOOD & BLOOD COMPONENTS TRANSFUSIONDATE : 08.10.04DOCUMENT NO : E5 AF5.4PAGE No. 1/3

NNA : E5 AF 5.4

Standard: All patients receive blood / blood component as prescribed. Objective : To ensure safe administration of blood / blood components. To detect reactions related to blood / blood component transfusion. Date of Audit :Locality :Auditors : 1.. 2.....N.B. Instructions For Auditors1. To tick [] in the appropriate column.

NNA : E5 AF 5.4

S/NITEMSOURCE OF INFORMATIONYESNON/A1Confirm patient identification.Ask patient his name or check bracelet.2Confirm prescription.Check doctors order in patients case notes.3Verify right blood / blood components.Observe nurse & check written evidence.

NNA : E5 AF 5.4

S/NITEMSOURCE OF INFORMATIONYESNON/A4Verify right blood / blood component for transfusionObserve nurse and check written evidence.5Verify screening.Observe nurse and check written evidence.

6Verify expiry date.Observe nurse and check written evidence.

NNA : E5 AF 5.4

S/NITEMSOURCE OF INFORMATIONYESNON/A7Perform baseline monitoring.Observe nurse.8Carry out regular monitoring.Observe nurse / Ask patient / Check written evidence.9Monitor time limit.Observe nurse / Ask patient / Check written evidence.

NNA : E5 AF 5.4

S/NITEMSOURCE OF INFORMATIONYESNON/A10Identify reactions.Observe nurse / Ask patient / Check written evidence.11Take appropriate measures if required.Observe nurse / Ask patient / Check written evidence.

NNA : E5 AF 5.4

S/NITEMSOURCE OF INFORMATIONYESNON/A12Check for accuracy and completeness of documentation.Observe nurse / Ask patient / Check written evidence.

AUDIT REPORT (Please [ ] the appropriate box)

Conformance Non-Conformance

REMARKS

Auditor 1 [Name and Signature] :

Auditor 2 [Name and Signature] :