Documentation of the clinical blood transfusion practice at a teaching and referral hospital in Western Kenya

Abstract

Blood transfusion is an essential component of modern health care. It can restore normal life expectancy and improve quality of life when used safely. Blood is scarce, costly and its use could be associated. with complications. Good clinical practice, which includes proper documentation, ensures safe and effective transfusion practice. The objective of the study was to analyze the process of documenting the clinical blood transfusion practice at public teaching and referral hospital. A hospital based medical chart review of 384 patients who were transfused from June 2013 to November 2013 was carried out. Systematic random sampling method was used to sample the patient medical charts and a data was collected using a structured data collection. Data was analyzed using frequency tables and is presented in form of text, tables and charts. Approval was obtained from Institutional Research and Ethical Committee of Moi University and the patient’s medical records were de-identified. The median age of the recipients was 31.5 years (IQR 13, 45.8) and the range was 1 day to 89 years. Females comprised 55.2% of the recipients. The indication of the transfusion, pre-transfusion Hb, consent, blood and blood product unit number, start times, duration of transfusion and observations of vital signs were documented in the charts of 91.1%. 99.0%, 0.8%, 73.4%, 43%, 47.1% and 27.6% of all the recipients respectively. It was concluded that there were inadequacies in the documentation of the transfusion process. The strategies of clinical audit and continuing medical education of health workers ought to be applied in order to improve the documentation of the clinical practice of blood transfusion. In addition, studies to establish the reasons for inadequate documentation of the transfusion process should be carried out