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Paper based system can achieve 100% traceability in transfusion-an audit report


  • Pathology

Document Type

Published Date

  • 2014-10


  • The Blood Safety and Quality Regulations 2005 require 'unambiguous traceability' of all blood and blood components from a donor to patient, or the final destination of all blood and its components if not transfused. Achieving 100% traceability is considered difficult and often electronic blood tracking system has to be purchased to maintain 100% traceability. The electronic blood tracking system has a varied degree of success and only few studies have achieved 100% traceability. Given the current financial climate in the NHS it is difficult to obtain funding and the mis-scanning of blood product and skipped steps during the process highlights the vulnerability of the electronic tracking system. At Burton Hospitals NHS Foundation Trust we have used the paper based system effectively and we have been able to achieve 100% traceability We reviewed our paper based system and the process for haemovigilance and looked at a month's data. A retrospective audit was done during the month of April to evaluate the effectiveness of the paper based system. The data was collected from the data warehouse through LABS project and from the issue transfusion follow up sheet. Our audit shows that we had 423 transfusions including blood and blood products in the month of April. 413(97.4%) issue transfusion forms were returned within the stipulated 3 day period. On further follow up by phoning the ward 4 more forms were returned on the 6th day from transfusion. An adverse incident was logged for the remaining transfusions and the transfusion practioner was able to end fate the unit by obtaining information from the patient's drug administration notes. Conclusion: Our audit shows that paper based system can be effective in achieving 100% traceability of transfusion in a medium sized district general hospital.
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