Quality Audit Preparation
Report Validation to include Blood Bank IT system
Blood Transfusion Laboratory
Blood Transfusion Care Pathway
- Blood Bank Staff (BMS or BSW under supervision)
- Transfusion Practitione
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?
- Document control - If copies have been issued, can they be traced?
- Are any copies correct/current?
Additional Evidence required:
- Evidence of training & awareness?
- Patient request form.
- Printed report corresponding to above request.
- Printout of Aucom routines appropriate to selected report.
- Barcode numbers of any products issued in association with the selected report.
- Evidence of change control over the reporting process?
- Staff awareness of process
- Is IT security sufficient to prevent untrained or unauthorised staff authorising results or amending reports?
- Are the set up procedures for report routines e.g. Aucom or MREP only accessible by authorised staff?
- Do staff log in to IT system using own user name/password?
- Is request form available?
- Do all patient demographics between request form and IT system correspond?
- If authorisation of results generates extra tests via an Aucom routine has the test/correct test been generated?
- If authorisation of results generates comments via an Aucom routine has the appropriate comment been generated?
- Is a report printed?
- Is there a record that a report has been printed?
- Do recorded results on computer correspond to those printed on the report?
- Is the report legible/understandable?
- Are the reports checked for correctness before issue?
- Has the member of staff logged off from the IT system?
- If a report is incorrectly printed/badly printed is there an SOP which tells staff what to do, who to speak to
- Have the staff been trained, correctly documented, for changing printer cartridges etc.