NATIONAL OPERATING ROOM NURSING AUDIT (NORNA)

PERIOPERATIVE CONTINUUM OF CARE

RECEIVING BLOOD/BLOOD PRODUCTS, STORAGE AND HANDING OVER
TO WARD NURSES
CHAIRPERSON
MATRON HAJJAH ZURINA BINTI HAJI HAMZAH
TEAM MEMBERS
Nursing Division Hospital Kuala Lumpur
KJ
KJ
KJ
KJ
KJ
KJ
KJ
KJ

Sh Zuraidah Syed Agir @ Syed Akil

B.Daiyawathy a/p B.Simeon
Nor Hayati Abdul Hamid
Salasiah Bahari
Rizalniyana Abd.Razak
Noor Hayati Mohd.Yussof
Hamidah Alias
Eilanchilvee a/p V.K Arumugam

1. INTRODUCTION
Blood / blood product in surgery and anesthesia is usually indicated in
major cases, anemia, cases of severe blood loss and coagulopathy, in
the operating theatre. Operating room nurses are to ensure that
blood / blood products required are correctly received and readily
available for use when required during surgery. Standard of practice
must be adhered to ensure patient safety. Accurate and complete
documentation of all information pertaining to blood / blood product
during receiving, storage and handing over is important to avoid errors
and risks to patient.
2. OBJECTIVES
2.1 To ensure correct blood / blood products are received by the OR
nurses for patients undergoing surgery.
2.2 To ensure all blood / blood products are kept in designated shelf
in the blood fridge.
2.3 To ensure all relevant information of patients blood / blood
products are documented correctly and accurately.

2.4 To ensure all body / blood products are handed over correctly to
the ward nurses.

3. STANDARD
Correct blood / blood products are received for patients undergoing
surgery.
4. METHODOLOGY.
A survey was done to assess on conformance and non conformance of
nurses in the practice receiving, storage and hand over of blood and
blood products in the operating room. It is direct observation of the
process of receiving, storage, handing over and documentation of
blood and blood product in the OR. The survey was done to 100 staff
nurses working in Operation Theater. The study conducted by Nursing
Sister of various operation theaters.
5. TIME FRAME
One month
6. INCLUSION CRITERIA
All blood and blood products received by the reception nurse for
patients undergoing surgery.
7. EXCLUSION CRITERIA
Blood and blood products sent directly to the OR
8. INSTRUMENT
Check list (NORNA E5 AF5.6) One check list for one observation. See
figure 1:

Figure 1

NATIONAL OPERATING ROOM NURSING AUDIT

VERSION 1/2012

ELEMENT 5 : PERIOPERATIVE CONTINUUM OF CARE

DATE : 02/03/2012
TOPIC: 5.6 RECEIVING AND STORAGE
DOCUMENT NO: E5 AF 5.6

PAGE NO 1/3

AUDIT FORM
STANDARD:
Correct blood / blood products are received for patients undergoing surgery.
OBJECTIVES:
1. To ensure blood / blood products are correct and safely received by the OR
nurse.
2. To ensure OR nurses store the blood / blood products in the blood fridge.
3. To ensure the nurse documents and complete relevant records accurately

Date of Audit:.
Locality :
Auditor : 1.
: 2.

National Operating Room Nursing Audit Mac 2012

NB. Instruction for Auditors

To tick () at the appropriate column.
S/N
O

T1

T2

SOURCE OF
INFORMATION

ITEM
RECEIVING
T1.1 Verify correct blood and blood
products received (as in EMR / Pt
Medical Record) with:T1.1.1. Blood request form
T1.1.2. Blood Pack
T1.1.3. Blood card
D1.2 Document blood received in
Blood Record Book
D1.3 Enter details in Blood Storage
Identification Label
T1.4 Place blood packs and label into
a transparent plastic bag
STORAGE
T2.1 Place the bag of blood in blood
fridge
T2.2 Inform anesthetist / surgeon / GA
nurse number of pack of blood
available
D2.3 Document in the OT list number
of blood packs and blood product
received.

AUDIT REPORT
(Please () the appropriate box)
RATING

Observe nurse
Observe
Observe
Observe
Observe nurse
Observe nurse
Observe nurse
Observe nurse
Listen and
Observe nurse
Observe

YE
S

N
O

N/
A

Conformance

Non Conformance

Technical
Documentation
REMARK

National Operating Room Nursing Audit Mac 2012

NATIONAL OPERATING ROOM NURSING AUDIT

RECEIVING AND STORAGE
1/2013
AUDIT FINDING IN PERCENTAGE:
LOCALITY
: OPERATING THEATRE, HKL
S/N
O

YES
(%)

NO
(%)

N/A
(%)

100

100

T1.1.2. Blood Pack

100

T1.1.3. Blood card

100

100

100

100

100

100

100

ITEM
RECEIVING
T1.1 Verify correct blood and blood products
received (as in EMR / Pt Medical Record) with:T1.1.1. Blood request form

T1

D1.2 Document blood received in Blood Record

Book
D1.3 Enter details in Blood Storage
Identification Label
T1.4 Place blood packs and label into a
transparent plastic bag
STORAGE
T2.1 Place the bag of blood in blood fridge

T2

T2.2 Inform anesthetist / surgeon / GA nurse

number of pack of blood available
D2.3 Document in the OT list number of blood
packs and blood product received.

NATIONAL OPERATING ROOM NURSING AUDIT

RECEIVING AND STORAGE
1/2013
AUDIT FINDING
LOCALITY
: OPERATING THEATRE, HKL
TOTAL NUMBER OF AUDIT
: 50 STAFF NURSES
S/N
O

ITEM

YES

NO

N/A

50

50

T1.1.2. Blood Pack

50

T1.1.3. Blood card

50

50

50

50

50

50

50

RECEIVING
T1.1 Verify correct blood and blood products
received (as in EMR / Pt Medical Record) with:T1.1.1. Blood request form
T1

D1.2 Document blood received in Blood Record

Book
D1.3 Enter details in Blood Storage
Identification Label
T1.4 Place blood packs and label into a
transparent plastic bag
STORAGE
T2.1 Place the bag of blood in blood fridge

T2

T2.2 Inform anesthetist / surgeon / GA nurse

number of pack of blood available
D2.3 Document in the OT list number of blood
packs and blood product received.

50

Figure 1
AUDIT FORM
NATIONAL OPERATING ROOM NURSING AUDIT
(NORNA)
ELEMENT 5 : PERIOPERATIVE CONTINUUM OF CARE
TOPIC : 5.6 HAND OVER BLOOD/BLOOD PRODUCT TO
WARD NURSE
DOCUMENT NO : E5 AF 5.6

VERSION 1/2012
DATE : 02/03/2012

PAGE NO 1/3

1. STANDARD:
Nurses hand over correctly all used and unused blood and blood products to
the ward nurse.
2. OBJECTIVES:
2.1
To ensure the OR nurses return correctly all used and unused blood
packs
and blood products to the ward nurses.
2.2

To ensure the nurse document and complete the relevant

Date of Audit :
Locality

Auditor

: 1.
: 2

National Operating Room Nursing Audit Mac 2012

NB. Instruction for Auditors

To tick () at the appropriate column.
S/N
O

T3

D4

SOURCE OF
YE N N/
INFORMATION
S
O
A
HANDING OVER (USED AND UNUSED) BLOOD PACKS TO WARD
NURSE
T3.1 Post Operative
ITEM

T3.1.1 Check total number of used

Observe nurse
and unused blood packs and blood
product
T3.1.2 Hand over to ward nurse
used / unused blood packs and blood
Observe nurse
products
DOCUMENTATION
Verify documentation of blood packs
used and unused in the blood record
Observe
book

AUDIT REPORT
(Please () the appropriate box)
RATING
Conformance
Technical
Documentation

Non Conformance

REMARK

National Operating Room Nursing Audit Mac 2012

NATIONAL OPERATING ROOM NURSING AUDIT

1/2013
HAND OVER BLOOD / BLOOD PRODUCT TO WARD NURSE
AUDIT FINDING IN PERCENTAGE:
LOCALITY
: OPERATING THEATRE, HKL

S/N
O

T3

D4

YES
NO
N/A
(%)
(%)
(%)
HANDING OVER (USED AND UNUSED) BLOOD PACKS TO WARD
NURSE
T3.1 Post Operative
ITEM

T3.1.1 Check total number of used and unused

blood packs and blood product
T3.1.2 Hand over to ward nurse used / unused
blood packs and blood products
DOCUMENTATION
Verify documentation of blood packs used and
unused in the blood record book

100

100

100

NATIONAL OPERATING ROOM NURSING AUDIT

1/2013
HAND OVER BLOOD / BLOOD PRODUCT TO WARD NURSE

AUDIT FINDING:
LOCALITY
: OPERATING THEATRE, HKL
TOTAL NUMBER OF AUDIT
: 50 STAFF NURSES
S/N
O

ITEM

YES

NO

N/A

HANDING OVER (USED AND UNUSED) BLOOD PACKS TO WARD

NURSE
T3.1 Post Operative
T3

D4

T3.1.1 Check total number of used and unused

blood packs and blood product
T3.1.2 Hand over to ward nurse used / unused
blood packs and blood products
DOCUMENTATION
Verify documentation of blood packs used and
unused in the blood record book

10

50

50

50

RESULT ON TECHNICAL FOR THE FIRST AUDIT

CONFORMA
NCE (%)

NON
CONFORMA
NCE
(%)

NA
(%)

100

T1.1.1

RECEIVING
Verify correct blood
and blood products
received (as in EMR /
Pt Medical Record)
with:Blood request form

100

T1.1.2

Blood Pack

100

T1.1.3

Blood card

100

NO OF
CHECKLI
ST
T1.1

T1.4

T2.1
T2.2

T3.1.1

PROCESS

Place blood packs

and label into a
100
transparent plastic
bag
STORAGE
Place the bag of
100
blood in blood fridge
Inform anesthetist /
surgeon / GA nurse
100
number of pack of
blood available
HANDING OVER (USED AND UNUSED)
WARD NURSE
Check total number
100
of used and unused
blood packs and

11

BLOOD PACKS TO
0

T3.1.2

blood product
Hand over to ward
nurse used / unused
blood packs and
blood products

100

RESULT ON DOCUMENTATION FOR THE FIRST AUDIT

NO OF
CHECKLI
ST
D1.2
D1.3

D2.3

D4

PROCESS

CONFORMA
NCE (%)

NON
CONFORMA
NCE
(%)

RECEIVING
Document blood
received in Blood
100
Record Book
Enter details in
Blood Storage
100
Identification Label
STORAGE
Document in the OT
list number of blood
100
packs and blood
product received.
HANDING OVER (USED AND UNUSED)
WARD NURSE
Verify
documentation of
blood packs used
100
and unused in the
blood record book

12

NA
(%)

BLOOD PACKS TO

NATIONAL OPERATING ROOM NURSING AUDIT

RECEIVED AND STORAGE, HAND OVER BLOOD /BLOOD PRODUCT
TO WARD
Analysis of total result on 1st Mei 2013 till 31st Mei 2013

TOTAL SAMPLE :
100
TOTAL

CONFORMANCE
(percentage)

NON
CONFORMANCE
(percentage)

NA
(percenta
ge)

100

100

100

PERFORMANCE
TECHNIQUE SKILL

DOCUMENTATION

13

RESULT OF AUDIT
From total of number of 50 study, this study was shown the higher
percentage conformance in receiving and storage, Hand over blood / blood
product to ward. This result shows 99% (99 staff nurses) performing
receiving and storage, Hand over blood / blood product to ward, and only 1%
(1 staff nurse) did not place blood packs and label into a transparent plastic
bag.
This study also shows that 2% (2 staff nurses) did not verify documentation
of blood packs used and unused in the blood record book.
REMEDIAL ACTION
A) Compliance to SOP.(HKL/BPK/OT/MP-13)
B) Regular audit twice per year will help to see improvement in
performing receiving and storage, Hand over blood / blood product to
ward.
CONCLUSION

14

Accurate and complete documentation of all information pertaining to

blood/blood product during receiving, storage and handing over is important
to avoid errors and risks to patients follow SOP.
REFERENCE
1. Manual prosedur kerja.
2. Senarai semak Safe Surgery Saves Lives.(SSL_POCL_09 VER 1.1)

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