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

Incident reporting - Quality Incident Reporting

Quality Audit Preparation

Process:

Quality Incident Reporting

Area:

Blood Transfusion Laboratory

Blood Transfusion Care Pathway

Auditees:

  • Blood Bank Staff (BMS/BSW under supervision)
  • Transfusion Practitioner

Initial preparation:

SOP Review is it:

  • Readily located?
  • In correct Trust format?
  • In date?
  • Fully signed/approved?
  • Master or Copy?
  • Is there evidence of regular review?
  • Is the document complete with all appendicies?
  • Is a risk assessment attached?
  • Has the document been equality assessed?

Additional Evidence required:

  1. Document control - If copies have been issued, can they be traced?
  2. Are any copies correct/current?
  3. Evidence of training & awareness?
  4. Availability of incident records
  5. Evidence of review
  6. Availability of IR1’s

Interviews/process:

  1. Staff awareness of process
  2. Awareness of SABRE
  3. What constitutes an incident?
  4. Availability of “Incident forms” for reporting
  5. Is the process evident in the laboratory (Posters/notices)
  6. Have implementers had Root cause analysis training?
  7. Who is the SABRE reporter?
  8. Can they demonstrate SABRE access & evidence of reports?

Additional requirements:

  1. Are Telephone logs in regular & accurate use?
  2. Evidence of SHOT reporting & near misses
  3. Are incidents appropriately investigated?
  4. Are incidents escalated through the Trust process?
  5. Review of the Departmental Risk register