A01 Clinical Audit: Adherence to Standard Operating Procedure of Blood Transfusion in Emergency and Trauma Department, Hospital Sultanah Nur Zahirah

Abstract

INTRODUCTION
Blood transfusion is a vital but potentially risky procedure if protocols are not followed. This audit aimed to assess compliance with the Standard Operating Procedure (SOP) for blood transfusion among Emergency and Trauma Department (ETD) staff at Hospital Sultanah Nur Zahirah (HSNZ), using a standardized checklist, and to identify gaps contributing to transfusion errors.

INTERVENTION
A Continuing Medical Education (CME) session was conducted to enhance awareness and reinforce adherence to the SOP. Educational materials, including a video and an informational flyer summarizing key steps, were distributed via both physical and digital platforms. Ongoing reminders were shared through departmental messaging groups to ensure consistent reinforcement across all teams and shifts.

DATA COLLECTION, ANALYSIS AND RESULTS
A prospective cross-sectional audit was conducted in two phases: Phase 1 (September–October 2024) and Phase 2 (January–February 2025). Five standards were assessed: blood sampling, product collection, pre-transfusion checks, final checks, and patient monitoring.
Post-intervention findings showed improved compliance in Standard 1 (Sampling): from 87% to 93%, and Standard 5 (Monitoring): from 67% to 80%. Full compliance (100%) was achieved in Standards 2, 3, and 4, indicating strong adherence to critical transfusion steps.

DISCUSSION
The interventions enhanced SOP adherence and reduced the potential for errors, ultimately improving patient safety. Regular review of transfusion practices helps identify gaps, reinforce best practices, and ensure safe, effective transfusion therapy.

CONCLUSION AND IMPLICATIONS
Although improvements were noted, achieving full compliance remains a challenge. Continued training, routine audits, and stricter enforcement are essential to close existing gaps and maintain safe transfusion practices.

https://doi.org/10.64392/8pjxm215