City of Hope Orange County Irvine, California, United States
Background/Case Studies: Achieving complete compliance with transfusion documentation remains a challenge across healthcare systems. This quality improvement (QI) initiative, conducted at a newly opened outpatient cancer center, aimed to improve adherence to regulatory standards, enhance patient safety, and strengthen transfusion documentation through collaboration between the blood bank and nursing departments.
Study
Design/Methods: A joint QI initiative was developed by blood bank and nursing to identify and address documentation gaps in blood transfusion administration. Key interventions included routine audits of electronic health record (EHR) transfusion entries, monthly reviews of findings, and targeted communication with frontline staff. Documentation was audited for seven regulatory components: pre-transfusion vital signs, 15-minute vital signs, post-transfusion vital signs, completeness of all required vitals (temperature, pulse, respiratory rate, blood pressure), transfusion volume, transfusion reaction assessment, and post-transfusion instructions. Statistical analysis was performed using RStudio (version 2023.06.0).
Results/Findings: Baseline analysis included 26 charts (10% of 272 transfusions), and post-intervention analysis included 92 charts (23% of 402 transfusions). Overall compliance improved from 19% (5/26) to 86% (79/92) post-intervention (χ² = 40.70, p < 0.0001; Fisher’s exact test p < 0.0001). Missing entries across all components decreased from 18% (33/182) to 2.5% (16/644) (χ² = 59.49, p < 0.0001; Fisher’s exact test p < 0.0001).
Conclusions: Structured collaboration between blood bank and nursing resulted in significant improvements in transfusion documentation compliance. Staff feedback highlighted improved communication, clearer understanding of policies, unified policy interpretation, and a shared sense of accountability. Additionally, a positive reinforcement system, which recognizes nurses who consistently achieve 100% documentation compliance, fostered a friendly spirit of competition, and sustained high performance. These findings support the value of interdepartmental cooperation in promoting regulatory compliance and patient safety.
