Audit of Blood
Audit of Blood
1. INTRODUCTION
Blood / blood product in surgery and anesthesia is usually indicated in
major cases, anemia, cases of severe blood loss and coagulopathy, in
the operating theatre. Operating room nurses are to ensure that
blood / blood products required are correctly received and readily
available for use when required during surgery. Standard of practice
must be adhered to ensure patient safety. Accurate and complete
documentation of all information pertaining to blood / blood product
during receiving, storage and handing over is important to avoid errors
and risks to patient.
2. OBJECTIVES
2.1 To ensure correct blood / blood products are received by the OR
nurses for patients undergoing surgery.
2.2 To ensure all blood / blood products are kept in designated shelf
in the blood fridge.
2.3 To ensure all relevant information of patients blood / blood
products are documented correctly and accurately.
2.4 To ensure all body / blood products are handed over correctly to
the ward nurses.
3. STANDARD
Correct blood / blood products are received for patients undergoing
surgery.
4. METHODOLOGY.
A survey was done to assess on conformance and non conformance of
nurses in the practice receiving, storage and hand over of blood and
blood products in the operating room. It is direct observation of the
process of receiving, storage, handing over and documentation of
blood and blood product in the OR. The survey was done to 100 staff
nurses working in Operation Theater. The study conducted by Nursing
Sister of various operation theaters.
5. TIME FRAME
One month
6. INCLUSION CRITERIA
All blood and blood products received by the reception nurse for
patients undergoing surgery.
7. EXCLUSION CRITERIA
Blood and blood products sent directly to the OR
8. INSTRUMENT
Check list (NORNA E5 AF5.6) One check list for one observation. See
figure 1:
Figure 1
VERSION 1/2012
PAGE NO 1/3
AUDIT FORM
STANDARD:
Correct blood / blood products are received for patients undergoing surgery.
OBJECTIVES:
1. To ensure blood / blood products are correct and safely received by the OR
nurse.
2. To ensure OR nurses store the blood / blood products in the blood fridge.
3. To ensure the nurse documents and complete relevant records accurately
Date of Audit:.
Locality :
Auditor : 1.
: 2.
T1
T2
SOURCE OF
INFORMATION
ITEM
RECEIVING
T1.1 Verify correct blood and blood
products received (as in EMR / Pt
Medical Record) with:T1.1.1. Blood request form
T1.1.2. Blood Pack
T1.1.3. Blood card
D1.2 Document blood received in
Blood Record Book
D1.3 Enter details in Blood Storage
Identification Label
T1.4 Place blood packs and label into
a transparent plastic bag
STORAGE
T2.1 Place the bag of blood in blood
fridge
T2.2 Inform anesthetist / surgeon / GA
nurse number of pack of blood
available
D2.3 Document in the OT list number
of blood packs and blood product
received.
AUDIT REPORT
(Please () the appropriate box)
RATING
Observe nurse
Observe
Observe
Observe
Observe nurse
Observe nurse
Observe nurse
Observe nurse
Listen and
Observe nurse
Observe
YE
S
N
O
N/
A
Conformance
Non Conformance
Technical
Documentation
REMARK
YES
(%)
NO
(%)
N/A
(%)
100
100
100
100
100
100
100
100
100
100
ITEM
RECEIVING
T1.1 Verify correct blood and blood products
received (as in EMR / Pt Medical Record) with:T1.1.1. Blood request form
T1
T2
ITEM
YES
NO
N/A
50
50
50
50
50
50
50
50
50
50
RECEIVING
T1.1 Verify correct blood and blood products
received (as in EMR / Pt Medical Record) with:T1.1.1. Blood request form
T1
T2
50
Figure 1
AUDIT FORM
NATIONAL OPERATING ROOM NURSING AUDIT
(NORNA)
ELEMENT 5 : PERIOPERATIVE CONTINUUM OF CARE
TOPIC : 5.6 HAND OVER BLOOD/BLOOD PRODUCT TO
WARD NURSE
DOCUMENT NO : E5 AF 5.6
VERSION 1/2012
DATE : 02/03/2012
PAGE NO 1/3
1. STANDARD:
Nurses hand over correctly all used and unused blood and blood products to
the ward nurse.
2. OBJECTIVES:
2.1
To ensure the OR nurses return correctly all used and unused blood
packs
and blood products to the ward nurses.
2.2
Date of Audit :
Locality
Auditor
: 1.
: 2
T3
D4
SOURCE OF
YE N N/
INFORMATION
S
O
A
HANDING OVER (USED AND UNUSED) BLOOD PACKS TO WARD
NURSE
T3.1 Post Operative
ITEM
AUDIT REPORT
(Please () the appropriate box)
RATING
Conformance
Technical
Documentation
Non Conformance
REMARK
S/N
O
T3
D4
YES
NO
N/A
(%)
(%)
(%)
HANDING OVER (USED AND UNUSED) BLOOD PACKS TO WARD
NURSE
T3.1 Post Operative
ITEM
100
100
100
AUDIT FINDING:
LOCALITY
: OPERATING THEATRE, HKL
TOTAL NUMBER OF AUDIT
: 50 STAFF NURSES
S/N
O
ITEM
YES
NO
N/A
D4
10
50
50
50
NON
CONFORMA
NCE
(%)
NA
(%)
100
T1.1.1
RECEIVING
Verify correct blood
and blood products
received (as in EMR /
Pt Medical Record)
with:Blood request form
100
T1.1.2
Blood Pack
100
T1.1.3
Blood card
100
NO OF
CHECKLI
ST
T1.1
T1.4
T2.1
T2.2
T3.1.1
PROCESS
11
BLOOD PACKS TO
0
T3.1.2
blood product
Hand over to ward
nurse used / unused
blood packs and
blood products
100
D2.3
D4
PROCESS
CONFORMA
NCE (%)
NON
CONFORMA
NCE
(%)
RECEIVING
Document blood
received in Blood
100
Record Book
Enter details in
Blood Storage
100
Identification Label
STORAGE
Document in the OT
list number of blood
100
packs and blood
product received.
HANDING OVER (USED AND UNUSED)
WARD NURSE
Verify
documentation of
blood packs used
100
and unused in the
blood record book
12
NA
(%)
BLOOD PACKS TO
TOTAL SAMPLE :
100
TOTAL
CONFORMANCE
(percentage)
NON
CONFORMANCE
(percentage)
NA
(percenta
ge)
100
100
100
PERFORMANCE
TECHNIQUE SKILL
DOCUMENTATION
13
RESULT OF AUDIT
From total of number of 50 study, this study was shown the higher
percentage conformance in receiving and storage, Hand over blood / blood
product to ward. This result shows 99% (99 staff nurses) performing
receiving and storage, Hand over blood / blood product to ward, and only 1%
(1 staff nurse) did not place blood packs and label into a transparent plastic
bag.
This study also shows that 2% (2 staff nurses) did not verify documentation
of blood packs used and unused in the blood record book.
REMEDIAL ACTION
A) Compliance to SOP.(HKL/BPK/OT/MP-13)
B) Regular audit twice per year will help to see improvement in
performing receiving and storage, Hand over blood / blood product to
ward.
CONCLUSION
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