Audit: A Presentation

1. Audit: A Presentation By Susan Mitchell, FIBMS Acting Chief BMS Blood Transfusion

2. Not a good start • Major panic at beginning of week

3. Audit and Audit Checklists • Two audits done for this activity • Horizontal and vertical audit • No audit checklist available within the trust for horizontal audits and staff have received no training • Haphazard approach to horizontal audits as no pre defined questions to ask of process being audited • Drew up a checklist for this horizontal audit, emailed quality manager re formal checklist for future horizontal audits. • No plans for trust wide format but have permission to draw up checklists for future horizontal audits • Vertical audit template includes checklist with questions applicable to following samples through a entire process

4. Horizontal Audit Checklist

5. Non Compliances and Quality Improvement Notes

6. Vertical Audit: Serological Crossmatch • Re-audit of 2008 vertical audit • Of benefit to laboratory as well as for the purposes of this course • Difficult to do as person assisting with audit had to cancel due to unforeseen circumstances beyond their control • When finally done, improvement on previous audit • Some previous non compliances had been corrected • Deeper look in some areas to find minor non compliances

7. Vertical Audit: Non Compliances • 13 non compliances in total • 2 non compliances found that were raised at previous audit • Crossmatch time not met, 27 minutes over • Private hospital samples not kept for time agreedin SLA and SOP • 11 other minor non compliances ( see handout) • 1 observation regarding size of reagent fridge • Recommendation for further audits to be done on the serological crossmatch to improve staff competencies

8. Vertical Audit: Quality Improvement Notes • Improved supervision of new staff- already undertaken • Deficiencies in handbook/forms- to be amended • Training logs- updating and review in progress, staff are asked to bring competeny logs to department for regular review • Proposal in place to ensure private hospital samples are kept for correct time • Calibration of thermometers ordered • All Post-It/handwritten amendments removed • Gaps in maintenance list have been signed • Non recording of downtime- staff are being reminded of importance of recording these • Trainee’s have undergone retraining and witnessed competencies are being up dated.

9. Horizontal Audit Conclusion • No SOP but there is an agreed template which is compliant with the BSQR’s • Out of date forms in SLA’s but current versions in use and document controlled • Most serious finding is the valid time for boxes but all staff aware of correct times and boxes are validated for the correct time (Clinimed website) • All non conformities will be corrected as the review dates come up • No guarantee that forms will not out date again as they are reviewed and the format improved.

10. Vertical Audit Conclusion • Improvement on previous audit • Two non compliances found previously • Shows importance of re audit • Many non compliances easy to correct and done on the day • Business case for a reagent fridge to be put forward • Additional witness audits started for serological crossmatch, it is possible to achieve in uder 1 hour