title: Lessons learned from transfusion audits.
abstract: BACKGROUND
  In times of patient blood management, studies focus on appropriate transfusion strategies to improve patient's outcome. Little is known about the quality assurance in preparation of blood transfusion and thereafter. In the present study, the indication, informed consent, mandatory immunohematology tests and documentation of blood transfusions were evaluated using assessed self-inspection forms approved by the hospital transfusion committee.
  
  
  METHODS
  47 medical records of transfused patients were retrospectively reviewed by a clinical transfusion audit team in six hospital facilities from 2012 to 2015. Self-inspection forms were used to classify the physicians' documentation of transfusion into 3 groups: adequately, intermediately, and inadequately documented.
  
  
  RESULTS
  Adequate documented records were only found in 5 cases (10.6%), followed by intermediate (51.1%) and inadequate documentation (38.3%). Informed consent was identified most often as inappropriate, and this was a critical point with respect to medico legal aspects.
  
  
  CONCLUSIONS
  Continuous education of physicians defining parameters to be documented is almost essential in daily transfusion medicine routine. The use of a check list with physician's documentation of transfusion is strongly recommended.
authors.affiliation: German Red Cross Blood Donor Service North-East, Institute Cottbus, 03050 Cottbus, Germany. Electronic address: r.moog@blutspende.de.
authors.forename: Rainer
authors.initials: R
authors.lastname: Moog
mesh_terms: D001803:Blood Transfusion; D005260:Female; D006801:Humans; D007258:Informed Consent; D008297:Male; D008485:Medical Audit; D008499:Medical Records
keywords: Audit; Documentation; Quality assurance; Transfusion