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Medical records contaminated with dried blood: A quality issue
M Fishman1, D J Mikolich, G G Fort
1Department of Nosocomial Infection, Our Lady of Fatima Hospital, North Providence, Rhode Island.
Abstract:
A routine chart review over 23 months in a 256-bed community hospital revealed 246 medical records contaminated with apparent blood. Sixty percent of the records were nursing and anesthesiology records. Analysis of systematically selected records confirmed blood as the visible contaminant in 27% of the cases (8/30). Total quality improvement methodology reduced the incidents by 75%. Actions included policy development, in-service education, and changes in work practices. Although bloodborne pathogen transmission is statistically improbable, we should improve work practices to eliminate blood contamination of charts.
Insights
A hospital chart review found 246 medical records contaminated with blood. Quality improvement initiatives significantly reduced these incidents, highlighting the need for better work practices to prevent chart contamination.
Area of Science:
- Healthcare Quality Improvement
- Patient Safety
- Medical Record Management
Background:
- Routine chart reviews identified significant blood contamination of medical records over 23 months.
- Nursing and anesthesiology records constituted the majority (60%) of contaminated documents.
- Visible blood contamination was confirmed in 27% of systematically analyzed records.
Purpose of the Study:
- To assess the prevalence of blood contamination in medical records.
- To evaluate the effectiveness of quality improvement interventions in reducing chart contamination.
- To emphasize the importance of improved work practices in preventing bloodborne pathogen exposure risks.
Main Methods:
- A retrospective chart review was conducted over a 23-month period in a community hospital.
- Systematic analysis was performed on a subset of contaminated records to confirm the contaminant.
- Total quality improvement (TQI) methodologies were implemented, including policy changes, education, and work practice modifications.
Main Results:
- A total of 246 medical records showed apparent blood contamination.
- Blood was confirmed as the contaminant in 27% of the records analyzed (8/30).
- Implemented quality improvement actions resulted in a 75% reduction in contamination incidents.
Conclusions:
- Despite low statistical risk of bloodborne pathogen transmission, blood contamination of medical records is a notable issue.
- Policy development, in-service education, and revised work practices are effective in reducing chart contamination.
- Continuous improvement in work practices is essential to eliminate blood contamination of patient charts.
