Wrong blood transfusion (BT) is a medical negligence. Every hospital must have a strong policy to check incorrect BT and see to it that these policies are strictly implemented at the time of transfusion.

Wrong BT can occur due to carelessness of the staff and shortcomings in verification of the blood bag. The reasons can be avoided and wrong BT can be prevented by the formation of a checklist consisting of the important details to be verified before initiating transfusion. The checklist should not be very long and time-consuming, but very comprehensive and consists of only absolutely essential things to be checked.

To study the BT process and providing suggestions for streamlining the process of BT.

• To analyze the nears miss incidents during BT.

• To identify the errors in the process of transfusion.

• To streamline the process by introducing checklist/work instructions for reducing errors.

• Analysis of safety reports regarding BT.

• Process-based root cause analysis was done at the time of issue and at ward level.

• Feedback regarding BT was taken from the staff working at blood bank and nursing professionals.

The study was divided into two phases:

Phase 1: January—April 2014

Phase 2: May—August 2014

All the reports from phase 1 of the study were analyzed. Based on the observations, interventions in the form of checklist and work instructions to the nursing staff were implemented in the hospital in the month of April and then the safety reports for the next 4 months were analyzed.

Interventions done: A “4C” checklist was created with just four elements that could be orally or mentally reviewed before beginning transfusion. Specific work instructions were also issued to the nursing staff at the ward level to prevent any errors during labeling of the samples being sent for cross match and blood grouping before BT.

The number of BT-related safety incidents observed in phase 1 reduced in phase 2 though the workload in terms of samples received remained comparable for the two phases. However, a declining trend for the reporting of incidents was also seen through the phases.

Shrivastava AA, Somu G, Dayananda M. Good Clinical Practices toward Safe Blood Transfusion: A Study of Blood Transfusion Process and providing Suggestions for streamlining the Same. Int J Res Foundation Hosp Healthc Adm 2016;4(1):1-4.