2024 Bedside Transfusion Practice

Key objectives

  • The key aim of this re-audit is to determine whether the current British Society of Haematology guideline ‘Administration of Blood Components’ (2017) is being followed and to determine if there has been any improvement in compliance compared to previous audit cycles. It also looks to assess whether any specially developed documentation or technologies used to support bedside transfusion practice have a beneficial effect. The audit seeks to understand the reasons for any areas for non-compliance, to help identify the barriers and facilitators of good practice.

What did we audit?

  • All NHS Trusts and independent hospitals in England were invited to participate in the audit. Trusts and hospitals in Wales, Northern Ireland and Scotland were also invited to participate. Data was submitted by Trusts as a whole and by individual hospitals. Therefore, the term “sites” is used throughout this report to refer to either Trust or hospital.
  • Sites were asked to provide data on a sample of up to 40 patients being transfused in the months of March and April 2024.

Who took part?

  • 127 sites contributed data
  • 2918 patients were analysed

What did we find?

Main findings 

  • The audit demonstrates overall reasonably safe practice but has identified areas for improvement.

  • Knowledge gaps, staffing pressures, lack of equipment (such as workstations on wheels, ID band printers), environmental factors (space, layout), set-up of systems (e.g. accessibility of a checklist) and varying practice in outpatient settings were all identified as contributing to poor compliance.

  • The prospective observational design of this audit enabled auditors to pick up errors or omissions as they happened and to take immediate corrective steps and provide education in real-time.

Checking process

  • A pre-transfusion checklist was not used in 14.1% (411/2918) of transfusions. 7.1% (12/168) of sites reported not having a checklist in place.

  • 67.3% (113/168) of sites have a policy requiring a two-person check before blood administration, and of those 70.6% (72/102) specify a two-person independent check. Of 1764 two-person checks observed, 833 (47.2%) were not carried out independently. Misunderstanding about the meaning of a two-person independent check was common.

  • 3.5% (137/3895) of checks were not carried out at the bedside.

  • The checking process was interrupted in 7.8% (210/2690) of cases but was only recommenced from the start in 49.0% (96/196). Most interruptions could be avoided by ensuring equipment, patient and prescription are all ready before collecting units.

Positive patient ID

  • 3.4% (99/2907) of patients were not wearing a form of ID, and in two thirds there was no appropriate reason for this.

  • In 7.0% (241/3434) of transfusion checks, the patient was not positively identified by asking them to state their name and date of birth, and these details were not checked against the ID band in 4.1% (140/3420).

Individual bedside checks

  • Compliance with most individual steps in the checking process was between 88% and 99%. A visual inspection of the unit (88.5% compliance, 3461/3910) and a check against special requirement stated on the prescription (92.6% compliance, 1444/1559) were most frequently missed.

  • A two-person independent check increased the likelihood that between them, one checker would cover every step.

Electronic systems

  • 36.3% (61/168) of sites have an electronic bedside system for pre-transfusion checks.

  • An electronic device was used in 25.0% (728/2913) of transfusion checks observed. Where an electronic device was used, there was lower percentage compliance with all steps of the staff checks, including those (positively identifying the patient, check of details against ID band, ensuring component matches prescription, visual inspection of unit) that the device cannot check.

Patient observations

  • A complete set of observations was not recorded pre-transfusion in 6.2% (178/2885) of cases, during transfusion (within 30 minutes of starting) in 11.7% (337/2878) and post-transfusion in 12.4% (354/2850).

Training

  • 94.8% (4426/4670) of staff performing bedside checks had completed transfusion training within the last 3 years, but 39 reported having no training and 205 (4.4%) were unsure. 

Our recommendations

  • Hospital transfusion teams should review their training on bedside transfusion practice to ensure:

    • This is in line with Trust policy (e.g. with regard to two-person independent checking, or number of staff required when using an electronic device)

    • This emphasises the reasons why checks are required, not just how to perform them

    • Refresher sessions/ bite-sized reminders of key points are available in between the main 2 or 3 year mandatory training cycle

  • Ensure a pre-transfusion checklist is available in a format facilitating easy use at the bedside.

  • When electronic bedside systems to support pre-transfusion checks are introduced, transfusion teams should ensure:

    • The systems are configured and equipment available so they can be used at the bedside

    • Training emphasises the continued importance of human checks, particularly those that the machine cannot perform (positive patient ID and check against wristband/ check against prescription/ visual inspection of unit)

    • They continue to review how the devices are used in practice and identify any workarounds which can erode the safety benefits
      If site audit has identified a cultural or systemic issue with ID bands (e.g. not being used in a particular setting) this should be escalated through hospital safety governance processes, as this represents a risk extending beyond transfusion.

  • If site audit has identified a cultural or systemic issue with ID bands (e.g. not being used in a particular setting, with no risk-assessed alternative) this should be escalated through hospital safety governance, as this represents a risk extending beyond transfusion.

  • Empower patients to view the ID check as a positive step to ensure their safety, and to ask for this if it has not been performed – this may be particularly applicable in regularly-transfused patients in an outpatient setting, where there is a risk of complacency.

  • Consider whether prompts can be built into the transfusion pathway, for example to ensure that equipment and patient are ready prior to collecting blood, and observations are taken. Electronic systems and integrated care plans may have a role in this.

  • Disseminate local audit findings via a top-down (nursing governance) and bottom-up (ward nurses in charge, staff huddles) approach, to ensure key messages reach the individuals performing these tasks day-to-day. This should include settings not involved in the original data collection. 

Useful resources

SHOT Safe transfusion checklist (PDF 747KB)

SHOT Using information technology for safe transfusion (PDF 2.5MB)