Shah Hospital, Kaithal Haryana

Ref.: SH/QD/BT/AR/No/08 Page 1 of 5

OBJECTIVE:

TO AUDIT THE BLOOD TRANSFUSIONS

DURATION:

JUNE-2023

AUDIT METHODOLOGY:

RETROSPECTIVE AUDIT OF BLOOD TRANSFUSIONS

PURPOSE OF AUDIT:

TO CHECK THE COMPLIANCE RATE TO BLOOD TRANSFUSION POLICY

AUDIT TOOL:

AN AUDIT TOOL IN THE FORM OF AN AUDIT CHECKLIST, TO COLLECT THE DATA FORM
BLOOD TRANSFUSION SHEETS.

SR- IPD/UHID YES NO NA

NO

1 REQUISITION FORM 100% 0% 0%

FILLED & SENT TO
BLOOD BANK

2 CONSENT OBTAIN FOR 100% 0% 0%

BLOOD TRANSFUSION

3 ENTRY MADE ON BLOOD 100% 0% 0%

TRANSFUSION
REGISTER ALONG WITH
DATE & TIME OF ORDER

4 TIME & TYPE OF BLOOD 100% 0% 0%

BAG
RECEIVED WRITTEN
(WITH QTY.)
 Shah Hospital, Kaithal Haryana
Ref.: SH/QD/BT/AR/No/08 Page 2 of 5

5 REASON OF TRANSFUSION 100% 0% 0%

MENTIONED
ON BT RECORD SHEET

6 TRANSFUSION RECORD 100% 0% 0%

FILLED AND COUNTER
CHECK BY TWO NURSES

7 DURATION OF 100% 0% 0%
TRANSFUSION WRITTEN

8 CLOSE MONITORING DONE 100% 0% 0%

TILL POST
TRANSFUSION AS PER
POLICY

9 POST-TRANSFUSION 100% 0% 0%
DOCUMENTATION DONE
BY DOCTOR

10 REACTION REPORTED 0% 0% 100%

AND ANALYSED IF
OCCURRED

11 POST-TRANSFUSION 100% 0% 0%
DOCUMENTATION DONE
BY THE NURSE

12 POST TRANSFUSION 100% 0% 0%

FEEDBCK TAKEN FROM
PATIENT
 Shah Hospital, Kaithal Haryana
Ref.: SH/QD/BT/AR/No/08 Page 3 of 5

GRAPHICAL REPRESENTATION- 1-3

100% 100% 100%

100%

80%

60%

40%

20%
0% 0% 0% 0% 0% 0%
0%
REQUISITION FORM CONSENT OBTAIN ENTRY MADE ON
FILLED & SENT TO FOR BLOOD BLOOD
BLOOD BANK TRANSFUSION TRANSFUSION
REGISTER
YES 100% 100% 100%
NO 0% 0% 0%
NA 0% 0% 0%

4-6

100% 100% 100%

100%
90%
80%
70%
60%
50%
40%
30%
20% 0% 0 0 0 0 0
10%
0%
TIME & TYPE OF REASON OF TRANSFUSION
BLOOD BAG TRANFUSION RECORD FILLED
RECEIVED MENTIONED ON AND COUNTER
WRITTEN (WITH BT RECORD CHECK BY TWO
QTY.) SHEET NURSES
YES 100% 100% 100%
NO 0% 0 0
NA 0 0 0

7-9
 Shah Hospital, Kaithal Haryana
Ref.: SH/QD/BT/AR/No/08 Page 4 of 5

100% 100% 100%

100%
80%
60%
40%
20% 0% 0% 0% 0% 0% 0%
0%
DURATION OF CLOSE TRANSFUSION AS POST-
TRANSFUSION MONITORING PER POLICY TRANSFUSION
WRITTEN DONE TILL POST DOCUMENTATIO
N DONE BY
DOCTOR
YES 100% 100% 100%
NO 0% 0% 0%
NA 0% 0% 0%

100% 100% 100%

100%
90%
80%
70%
60%
50%
40%
30%
20% 0% 0% 0% 0% 0% 0%
10%
0%
REACTION REPORTED AND POST-TRANSFUSION POST TRANSFUSION
ANALYSED IF OCCURRED DOCUMENTATION DONE FEEDBCK TAKEN FROM
BY THE NURSE PATIENT
YES 0% 100% 100%
NO 0% 0% 0%
NA 100% 0% 0%

FINDING-

© Requisitions were filled and sent to blood bank.

© Consent form was obtained appropriately in all transfusions.

© Entries were made on blood transfusion register by entering the time of request and
time of receiving with type of bag & quantity

© Reason of transfusion was mentioned on all consent forms.

© Blood transfusion record was filled appropriately with duration of transfusion on

The record sheet.

© Close monitoring done till the appropriate time during transfusion & post-transfusion.

© No reaction was reported in any transfusion.

 Shah Hospital, Kaithal Haryana
Ref.: SH/QD/BT/AR/No/08 Page 5 of 5

© Post-transfusion documentation was done by the doctor & nurse in all records

• Post-transfusion feedback was taken from patient all the patients after the transfusion

RECOMMENDATION-

• Blood transfusion policy is being followed appropriately.

• All the parameters are being followed and documentation is being done appropriately

Regular training must be given to all newly joined and old staff on blood transfusion policy

• Re-audit will be conducted to ensure the blood transfusion policy adherence

MRS. MANJEET KAUR MR. RAHUL NEGI DR.MS SHAH

(ICN) QUALITY MANAGER DIRECTOR