Quality Audit Preparation
- Blood bank staff BMS or MLA
- Blood Transfusion Co-ordinator
- Pathology Quality Services Manager
- Does it have a title?
- Does it have a unique identifier?
- Does it have a revision number?
- Does it have a date of implementation?
- Does it have a review date and has the SOP been regularly reviewed?
- Is the author identified?
- Has it been authorised by an appropriate member of staff?
- Are the number of copies and their locations identified?
- Is the history page up to date?
- Is there evidence that staff have signed and dated they have read and understood the SOP?
- Are there COSHH and risk assessments if relevant?
Additional Evidence required:
- Are there training and competency assessments for the member of staff performing the data entry task?
- Has the member of staff signed that they have read the current version of the SOP?
- Are there validation records for the Telepath system?
- Have VDU assessments been carried out?
- Are request forms stored as per retention of records policy?
- Does the Telepath user have a unique username and password?
- Does the Telepath system allow a complete audit trail of the data entry process?
- Does the member of staff understand the incident reporting process?
- Observation of the member of staff undertaking the data entry process in real time
- Question the member of staff in relation to actions required if the request form – fails in relation to the following information
- Patient details are not hand written
- No DOB
- No Hospital number
- No address
- Identification by patient wristband- box not ticked
- Positive verbal identification – box not ticked
- Take a selection of request cards and undertake a retrospective audit on the following:
- Legibility of request form
- Complete Patient information data
- Requesting clinician
- Hand written patient information
- Other information as appropriate to the test request required and type of patient e.g. antenatal
- Storage and retention and disposal of request forms
- Confidentiality of patient data
- Security of electronic patient data
- References to other policies e.g. minimum criteria for completion of request forms and rejection policy