Improving documentation of blood product administration using a standardized electronic health record–based system: a single-institution experience

Abstract

Objectives To improve documentation of blood product administration by assessing the completion status of blood transfusions. In this way, we can ensure compliance with the Association for the Advancement of Blood & Biotherapies standards and facilitate investigation of potential blood transfusion reactions. Methods This before-and-after study includes the implementation of an electronic health record (EHR)–based, standardized protocol for documenting the completion of blood product administration. Twenty-four months of retrospective data (January-December 2021) and prospective data (January-December 2022) were collected. Meetings were held before the intervention. Ongoing daily, weekly, and monthly reports were prepared, and targeted education to deficient areas as well as spot in-person audits by the blood bank residents were conducted. Results During 2022, 8,342 blood products were transfused, of which 6,358 blood product administrations were documented. The overall percentage of completed transfusion order documentation improved from 35.54% (units/units) in 2021 to 76.22% (units/units) in 2022. Conclusions Interdisciplinary collaborative efforts helped produce quality audits to improve the documentation of blood product transfusion through a standardized and customized EHR-based blood product administration module.

Blood Management: A Current Opportunity in Perioperative Medicine

“…The more the orders are used and experience increases with blood product transfusion, the more exposure there will be to this workflow, allowing for enhanced education. Also, the electronic health record can facilitate improved documentation of blood product transfusions, allowing the development of increased insight into potential blood product overuse [15].…”