Maintenance chart Fridge monthly

Background

This audit tool has been designed to help organisations gain an understanding of pre-operative transfusion practice.
Additionally, it can be used to provide evidence that an organisation is working towards/meeting the following NSQHS
Standard 7 criteria ( http://www.safetyandquality.gov.au/wp-content/uploads/2012/10/Standard7…):

• 7.8.2 Action is taken to minimising wastage of blood and blood products
• 7.4.1 Quality improvement activities are undertaken to reduce the risks of patient harm from transfusion practices and the clinical use of blood and blood products

The tool is designed to determine the crossmatch:transfusion ratio for the area audited. Generally, crossmatched units remain in
blood fridges allocated to the patient for whom they were requested for up to 3 days. After this period the laboratory can
accept the units back into their inventory provided that they have been stored and handled correctly and are within expiry. The
benefits of reducing the crossmatch:transfusion ratios include:

• reduced numbers of red cell units stored in the blood fridge, which may also reduce the risk of collecting the wrong blood product in error
• reduced workload for hospital staff who facilitate and document the movement of blood products into and out of the blood fridge via a blood register
• Waste minimisation through more effective management of red cell inventory in the transfusion laboratory. Nationally, red cell waste due to expiry prior to use accounts for 68% of total red cell waste (National Blood Authority July 14-April 15).

How to use the tool
The audit tool is designed to be used in conjunction with the blood fridge register. Together these will assist in establishing and
documenting the number of crossmatched red cells:

• stored in the blood fridge
• transfused
• returned to the laboratory (see example below).

The simple design of the tool adds to its flexibility and allows it to be used to audit any blood fridge within a health service. The
tool can be used to investigate the crossmatch:transfusion ratio for a particular clinical area by monitoring the movement of
blood into and out of a fridge for a specified period. Alternatively it could be used to investigate blood ordering practices for a
specific patient group (e.g. orthopaedic surgical patients) by monitoring blood movement for patients identified as belonging to
this group. The audit period is determined by the user (i.e. weekly, monthly etc.) and the tool lends itself to both real time and
retrospective data collection.