A tale of traceability

Abstract

Introduction: The Blood Safety and Quality Regulations (BSQR) 2005 require organisations to identify the fate of all blood components issued. The Medicines and Healthcare products Regulatory Agency (MHRA) monitors compliance and judge any value less than 100% as non-compliant. QEHB is a University Hospital based on two sites serving one other trust and eight smaller sites. We describe our experience in implementing measures to successfully achieve 100%. Methods Blood traceability was initiated in 2006, led by the newly appointed Hospital Transfusion Practitioner. Training was delivered to key staff groups. The importance of traceability is included in consultant and senior staff briefings. The individual administering blood is responsible for recording the fate in either the electronic prescribing system or a blood register. Product handlers, (transfusion MLAs) collect the information daily during ward visits and reconcile it with blood crossmatch forms. Patient notes are examined as required. Since March 2007, the system has been audited quarterly examining all blood issued for 5-7 days. The audit report includes current and past results for individual areas. An anonymised report is emailed individually to each ward manager with their own results highlighted. Good practice is congratulated. Results are reviewed at the Hospital Transfusion Committee and during customer service meetings. Results We issued approximately 35,000 units pa. Each audit covered approximately 600 units. The percentage split between the two trust sites, ROH and the community/private units was 72;21;5;1. The number of note reviews varied between 1-7%. Serial results from 2007 show a steady rise in traceability from 89% to 100% in all areas. A breakdown of results shows that most areas have had a sustained traceability of 100%. The area associated with slower progress has had no dedicated HTP but has recently had senior nursing support. Conclusions Full traceability has been achieved in a large trust managing a number of external contracts. We propose that factors associated with success include a Hospital Transfusion Practitioner; electronic prescribing; the human face of the blood bank within the clinical areas; timely feedback and reinforcing success.