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

Telephone log

Quality Audit Preparation

Process:

Telephone log

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?

Interviews/process:

  1. Observation of the member of staff answering the telephone in real time
  2. Is the manner in which the caller is dealt with satisfactory i.e polite
  3. Observe the member of staff completing the telephone log form / entering in LIMS with the information as required by the SOP e.g.
    • Patient ID
    • DOB
    • Hospital number
    • Message
    • Caller ID/Bleep No.
    • Requirements
    • Date and Time

Additional requirements:

  1. Take a selection of telephone logs and undertake a retrospective audit on the following:
    • Legibility
    • Complete Patient information data
    • Caller ID
    • Other information as appropriate to the task
  2. Storage and retention and disposal of tel logs
  3. Confidentiality of patient data