(P-TS-122) The Impact of a New Auditing Process on the Documentation of Blood Product Administration

Background/Case Studies: Transfusion of blood products is a common procedure performed in healthcare facilities and an essential part of patient treatment. Correct transfusion documentation plays a large role in providing safe blood product transfusions and should be performed according to the facility policy. Healthcare facilities are inspected on documentation requirements and performing routine audits can ensure that the staff involved in transfusions are following the established procedures. Transfusion audits are also required by hospital accrediting agencies but there are few reports on how well transfusion documentation is being performed, how to improve documentation compliance, and how changes in auditing can be evaluated to determine their effectiveness.

Study

Design/Methods: The purpose of this study was to determine if the implementation of a new audit process would significantly improve the documentation of blood product transfusions. The new audit included a 10% monthly review of all transfusions and feedback to nursing leadership regarding any areas of improvement. The study was achieved by comparing transfusion documentation from 240 transfusions one year before and one year after the implementation of the new audit process. The transfusion data collected was compared to the requirements listed in the facility’s transfusion policy to determine if there were documentation errors. This included clerical errors and missing information such as blood product details, patient vitals, and correct start and end time documentation.

Results/Findings: A chi square test of independence was utilized to compare the total number of documentation errors before and after the implementation of the new audit. According to the statistical analysis using a p < 0.05, there was not a significant difference in the amount of transfusion documentation errors between the two groups, X2(1,N=480) =.68, p=.41. The number of documentation errors increased post audit and vital-related omissions remained the most common error between the groups, as seen in Table 1.

Conclusions: The study did not find a significant difference in transfusion documentation errors before and after the implementation of a new transfusion audit process which indicates that the new process did not have the desired effect on improving blood product transfusion documentation. This could have been due to breakdowns in communication between leadership and transfusion staff regarding audit results. Further investigation regarding transfusion education may be warranted to determine if enhancements in training are needed for transfusion staff. Changes to the new audit process are still necessary to achieve improvements in transfusion documentation compliance.