Documenting a transfusion: how well is it done?
BACKGROUND
Current practice in transfusion medicine promotes clear documentation of transfusion-related events including the fact that the patient has been informed of the related risks and benefits.


METHODS
A retrospective review of 1005 patient charts was carried out to determine documentation.


RESULTS
Most patients were from general surgery (10.8%) and cardiac surgery (14.1%). In 75 percent of cases the physician had not documented that any discussion had occurred regarding the risks and/or benefits or alternatives. Only 12 percent of charts included information that the patient was subsequently told what blood components were given to them. The discharge summary recorded transfusion information in 32.1 percent of cases whereas the consult note had this information in 26.3 percent. Chart records matched the transfusion medicine records in 60.6 percent of cases. The most common error was in the blood unit identification number.


CONCLUSIONS
While accepted in theory, the practice of documenting patient information on transfusion is not well done.
Rock
Gail
G
Department of Pathology, and the Department of Epidemiology, University of Ottawa, Ottawa, Ontario, Canada. cag@ca.inter.net
Berger
Ray
R
Filion
Diane
D
Touche
Donna
D
Neurath
Doris
D
Wells
George
G
Elsaadany
Susie
S
Afzal
Mohammed
M
D001803:Blood Transfusion / Q000592:standards / Q000706:statistics & numerical data*; D002170:Canada; D004282:Documentation / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D007258:Informed Consent / Q000592:standards / Q000706:statistics & numerical data; D008499:Medical Records / Q000592:standards / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care / Q000592:standards / Q000706:statistics & numerical data; D012189:Retrospective Studies