Enhancing Protocol Adherence for Blood Transfusion Documentation

Abstract

Background: Blood transfusion is a high-risk nursing procedure that requires complete and accurate documentation to ensure patient safety, traceability, and compliance with regulatory standards. Baseline audits conducted in the Female Surgical Ward revealed incomplete entries, missing vital signs, and inconsistent adherence to protocol steps, which posed potential risks to patient outcomes and accreditation compliance.

Objectives: The project aimed to improve documentation accuracy and staff adherence to transfusion protocol, targeting ≥98% compliance by October 2025 through staff education, development of a standardized checklist, and continuous monitoring.

Methods: A quasi-experimental pre–post intervention study was conducted in the Female Surgical Ward. The intervention included development of a standardized blood transfusion documentation checklist, staff training, bedside coaching, and monthly audit feedback. Compliance rates were measured before and after implementation using structured audit tools.

Results: Documentation compliance improved markedly from 68% at baseline to 97% post-intervention. Staff adherence to transfusion protocol increased from 70% to 94%, while feedback response rate rose from 60% to 92%, demonstrating significant improvement across all indicators.

Conclusion: The intervention proved effective in enhancing documentation accuracy, improving staff competency, and strengthening patient safety practices. Standardization and continuous auditing were critical in sustaining improvement.