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.

Study Design And 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.