JPAC Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee

Data entry

Quality Audit Preparation

Process:

Data Entry

Area:

Blood Bank

Auditees:

  • Blood bank staff BMS or MLA
  • Blood Transfusion Co-ordinator
  • Pathology Quality Services Manager

Initial preparation:

SOP

  • 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:

  1. Are there training and competency assessments for the member of staff performing the data entry task?
  2. Has the member of staff signed that they have read the current version of the SOP?
  3. Are there validation records for the Telepath system?
  4. Have VDU assessments been carried out?
  5. Are request forms stored as per retention of records policy?
  6. Does the Telepath user have a unique username and password?
  7. Does the Telepath system allow a complete audit trail of the data entry process?
  8. Does the member of staff understand the incident reporting process?

Interviews/

process:

  1. Observation of the member of staff undertaking the data entry process in real time
  2. 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

Additional requirements:

  1. Take a selection of request cards and undertake a retrospective audit on the following:
    • Legibility of request form
    • Complete Patient information data
    • Source
    • Requesting clinician
    • Hand written patient information
    • Other information as appropriate to the test request required and type of patient e.g. antenatal
  2. Storage and retention and disposal of request forms
  3. Confidentiality of patient data
  4. Security of electronic patient data
  5. References to other policies e.g. minimum criteria for completion of request forms and rejection policy