JPAC Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee

Incident reporting - Quality Incident Reporting

Quality Audit Preparation


Quality Incident Reporting


Blood Transfusion Laboratory

Blood Transfusion Care Pathway


  • Blood Bank Staff (BMS/BSW under supervision)
  • Transfusion Practitioner

Initial preparation:

SOP Review is it:

  • Readily located?
  • In correct Trust format?
  • In date?
  • Fully signed/approved?
  • Master or Copy?
  • Is there evidence of regular review?
  • Is the document complete with all appendicies?
  • Is a risk assessment attached?
  • Has the document been equality assessed?

Additional Evidence required:

  1. Document control - If copies have been issued, can they be traced?
  2. Are any copies correct/current?
  3. Evidence of training & awareness?
  4. Availability of incident records
  5. Evidence of review
  6. Availability of IR1’s


  1. Staff awareness of process
  2. Awareness of SABRE
  3. What constitutes an incident?
  4. Availability of “Incident forms” for reporting
  5. Is the process evident in the laboratory (Posters/notices)
  6. Have implementers had Root cause analysis training?
  7. Who is the SABRE reporter?
  8. Can they demonstrate SABRE access & evidence of reports?

Additional requirements:

  1. Are Telephone logs in regular & accurate use?
  2. Evidence of SHOT reporting & near misses
  3. Are incidents appropriately investigated?
  4. Are incidents escalated through the Trust process?
  5. Review of the Departmental Risk register