Abstract

Problem: Failure of correct identification and insufficient monitoring of patients receiving transfusions continue to be appreciable and avoidable causes of morbidity and mortality.

Design: A study by a regional transfusion service and a transfusion nurse specialist of the effects of an education programme based on the current national guidelines on identification and monitoring of patients receiving transfusions.

Setting: A large United Kingdom teaching hospital which houses the headquarters of the regional transfusion service.

Key measures for improvement: Improvement in compliance with published national guidelines on the prescription and administration of blood transfusions.

Strategy for change: An audit of current compliance followed by dissemination by a transfusion nurse specialist of a clinical skills package (based on the best practice for transfusion) to all staff involved in giving transfusions. This was supported by trained instructors and the display of standard operating procedures for transfusion in all clinical areas.

Effect of change: An improvement in compliance with the national guidelines to over 95% in six out of seven of the recommendations on best practice was seen 18 months after the initial intervention.

Lessons learnt: The study shows that education of those who prescribe and administer transfusions, as recommended by bodies concerned with the hazards of transfusion, can improve the safety of transfusions.