BLOOD / BLOOD COMPONENT

TRANSFUSION

NNA : E5 .4

2. Purpose [Why Audit]

Blood and blood components are viewed

as

medication / treatment. All patients

undergoing blood / blood component
transfusions are subjected to potential
Any compromise in the quality of
will cause harm to the

risks.

management

patient and

predisposes the organization to litigations.

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

5. 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 Guide
6.1

Inclusion criteria

6.2

Exclusion criteria

NNA : E5 .4

6. Audit Guide [cont]

6.3

Instrument

6.4

Methodology

7.

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

6.4.1 Direct observation of blood /

blood component transfusion
and also gathering information
from documents.
6.4.2 Setting : All adult wards and
day care unit.
NNA : E5 .4

6.4.3

Population : Staff Nurses

6.4.4

Sample Design
-

Random sampling

NNA : E5 .4

6.4.5 Sample Size

- 20 transfusions, 18 from any
ward and 2 from day

adult

care.

6.5 Time 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 :

7.2.1 blood / blood component must be
transfused within 30 minutes of
removing the pack from
refrigeration.
7.2.2 to 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

7.2.3

appropriate time frame per pack

i]

whole blood : within 4 hours

ii]

packed cells : within 4 hours

iii]

fresh frozen plasma : within

30 minutes

iv]

cryoprecipitate : within 30
minutes

v]

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

7.3.1

confirm patient identification :

ask patient his name / check
bracelet

7.3.2

verify prescription : check doctors

order in patients case notes

NNA : E5 .4

7.3.3

verify 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 done

v] blood not expired

* No. [i] - [iv] to be verified together with the
doctor

NNA : E5 .4

7.4. Baseline and regular monitoring

7.4.1 patients blood pressure, pulse, respiration
and
temperature before administration
7.4.2 Initial 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],
site,

anaphylaxis, pain [infusion

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 :

7.7.1 blood card must be completed accurately
7.7.2 document in the intake-output
/ patients progress notes
of transfusion, blood

chart

[date &

type,

time

amount

transfused]
7.7.3 any transfusion reactions and
appropriate measures taken

NNA : E5 .4

7.8. Transfusion errors include any of the

following :
7.8.1 blood / blood component given not
according to prescription
7.8.2 blood 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 notes
7.8.4expired blood transfused

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7.8.5 did not confirm screening for

HbsAg,

HIV and VDRL or non-emergency

transfusion
7.8.6 transfusion 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 done

7.8.9

inappropriate personnel [e.g.

non-qualified staff] verifying blood

7.8.10 improper / 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

NATIONAL NURSING AUDIT

MINISTRY OF HEALTH MALAYSIA
VERSION 2/04
ELEMENT 5 : CONTINUUM OF CARE

TOPIC

: 5.4 BLOOD & BLOOD

COMPONENTS
TRANSFUSION

DATE : 08.10.04

DOCUMENT NO : E5 AF5.4

PAGE 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 Auditors
1. To tick [] in the appropriate column.
NNA : E5 AF 5.4

S/N

ITEM

SOURCE OF
INFORMATION

1 Confirm patient
identification.

Ask patient
his name or
check
bracelet.

2 Confirm
prescription.

Check
doctors order
in patients
case notes.

YES

NO

N/A

3 Verify right blood Observe

/ blood
nurse & check
components.
written
evidence.
NNA : E5 AF 5.4

S/N

ITEM

4 Verify right blood

/ blood
component for
transfusion

SOURCE OF
INFORMATION

YES

NO

N/A

Observe nurse
and check
written
evidence.

5 Verify screening. Observe nurse

and check
written
evidence.
6 Verify expiry
date.

Observe nurse
and check
written
evidence.

NNA : E5 AF 5.4

S/N

ITEM

7 Perform
baseline
monitoring.

SOURCE OF
INFORMATION

YES

NO

N/A

Observe
nurse.

8 Carry out regular Observe nurse

monitoring.
/ Ask patient /
Check written
evidence.
9 Monitor time
limit.

Observe nurse
/ Ask patient /
Check written
evidence.
NNA : E5 AF 5.4

S/N

ITEM

10 Identify
reactions.

SOURCE OF
INFORMATION

YES

NO

N/A

Observe
nurse / Ask
patient /
Check written
evidence.

11 Take appropriate Observe

measures if
nurse / Ask
required.
patient /
Check written
evidence.

NNA : E5 AF 5.4

S/N

ITEM

12 Check for
accuracy and
completeness of
documentation.

SOURCE OF
INFORMATION

YES

NO

N/A

Observe
nurse / Ask
patient /
Check written
evidence.

NNA : E5 AF 5.4

AUDIT REPORT
(Please [ ] the appropriate box)
Conformance

Non-Conformance

REMARKS
Auditor 1 [Name and Signature] :
Auditor 2 [Name and Signature] :