ABO and Rh Antigen Distribution Among Pregnant Women in South Western Uganda.

Introduction: ABO and Rh are the major blood group systems in Transfusion Medicine, the ABO system based on two red cell antigens (A, B) while the Rh has about 50 antigens of which five are highly clinically significant (D, C, c, E, e). These vary among races and ethnic groups. Blood type phenotype incompatibility between mother and fetus may result in antigen mismatch, triggering alloimmunization, and thus causing hemolytic transfusion reaction (HTR), which results in hemolytic disease of fetus and newborn (HDFN). This study aimed to determine the frequencies of ABO and rhesus blood group antigen in the pregnant women in South Western Uganda. Methods: A cross-sectional study was carried out on 1369 pregnant women who were recruited and provided consent to participate during their regular antenatal visits between August 2020 and July 2021. Four milliliters (4mL) of EDTA-anti-coagulated blood samples were collected and ABO and Rh-blood grouping including Rh antigen screening was done using the agglutination technology comprised of glass beads and reagent contained in a column of the Ortho Biovue ID Micro Typing System (Ortho Clinical Diagnostics, New Jersey, USA). The Rh antigen phenotypes and frequencies were then determined. Results: There was percentage distribution of 99.8%, c 99.3%, D 94.3%, C 19.2% and E 15.9%, with Rh cDe/cDe (65.1%) being the most common phenotype followed by cDe/CDe (15%), cDe/cDE (10.8%) and cDE/cDE 0.1% least common. The ABO grouping frequency was obtained as O 49.4%, A 29.5%, B 17.0% and AB 4.1%, with D positivity at 94.3%. Discussion: Population genetic variations result in varied expressions of red cell antigens that may have clinical complications. Knowledge of the presence of these Rh antigen distributions and phenotype frequencies during pregnancy help in rational management of the pregnancy, alloimmunization and better approach to safe blood transfusion.

The Mirasol Evaluation of Reduction in Infections Trial (MERIT): study protocol for a randomized controlled clinical trial.

BACKGROUND: Transfusion-transmitted infections (TTIs) are a global health challenge. One new approach to reduce TTIs is the use of pathogen reduction technology (PRT). In vitro, Mirasol PRT reduces the infectious load in whole blood (WB) by at least 99%. However, there are limited in vivo data on the safety and efficacy of Mirasol PRT. The objective of the Mirasol Evaluation of Reduction in Infections Trial (MERIT) is to investigate whether Mirasol PRT of WB can prevent seven targeted TTIs (malaria, bacteria, human immunodeficiency virus, hepatitis B virus, hepatitis C virus, hepatitis E virus, and human herpesvirus 8). METHODS: MERIT is a randomized, double-blinded, controlled clinical trial. Recruitment started in November 2019 and is expected to end in 2024. Consenting participants who require transfusion as medically indicated at three hospitals in Kampala, Uganda, will be randomized to receive either Mirasol-treated WB (n = 1000) or standard WB (n = 1000). TTI testing will be performed on donor units and recipients (pre-transfusion and day 2, day 7, week 4, and week 10 after transfusion). The primary endpoint is the cumulative incidence of one or more targeted TTIs from the Mirasol-treated WB vs. standard WB in a previously negative recipient for the specific TTI that is also detected in the donor unit. Log-binomial regression models will be used to estimate the relative risk reduction of a TTI by 10 weeks associated with Mirasol PRT. The clinical effectiveness of Mirasol WB compared to standard WB products in recipients will also be evaluated. DISCUSSION: Screening infrastructure for TTIs in low-resource settings has gaps, even for major TTIs. PRT presents a fast, potentially cost-effective, and easy-to-use technology to improve blood safety. MERIT is the largest clinical trial designed to evaluate the use of Mirasol PRT for WB. In addition, this trial will provide data on TTIs in Uganda. TRIAL REGISTRATION: Mirasol Evaluation of Reduction in Infections Trial (MERIT) NCT03737669 . Registered on 9 November 2018.

Transfusion Challenges in Patients with Hematological Malignancies in Sub-Saharan Africa: A Prospective Observational Study from the Uganda Cancer Institute.

Blood transfusion is fundamental in managing hematologic malignancies. We sought to evaluate the need and availability of blood products for patients with hematological malignancies at Uganda Cancer Institute. We prospectively studied the demand and supply of blood for patients with thrombocytopenia (platelet count ≤50 × 109/L), anemia (hemoglobin ≤10 g/dL), and bleeding (WHO grade ≥2). We used Poisson generalized estimating equation regression models for longitudinal binary outcomes. Among 91 patients, the median age was 26 years (IQR, 11-47). Thrombocytopenia occurred on ≥1 day in 58% of patients and on 49% of hospital days. Platelets were transfused to 39% of patients. The mean number of platelet units requested per day was 16.2 (range 0-30); 5.1 (range 0-15) were received. Anemia occurred on ≥1 day in 90% of patients; on 78% of days; and 68% received at least one blood transfusion. The mean number of blood units requested was 36.3 (range 8-57) units per day; 14 (range 0-30) were received. Bleeding occurred on ≥1 day in 19% of patients on 8% of hospital days. Thrombocytopenia and anemia were common, but product availability was substantially below that requested. We recommend increased blood collection and adherence to strict transfusion triggers as strategies to improve blood availability.

How low can you go: What is the safe threshold for platelet transfusions in patients with hematologic malignancy in sub-Saharan Africa.

BACKGROUND: Despite the importance of platelet transfusions in treatment of hematologic cancer patients, the optimal platelet count threshold for prophylactic transfusion is unknown in sub-Saharan Africa. METHODS: We followed patients admitted to the Uganda Cancer Institute with a hematological malignancy in 3 sequential 4-month time-periods using incrementally lower thresholds for prophylactic platelet transfusion: platelet counts ≤ 30 x 109/L in period 1, ≤ 20 x 109/L in period 2, and ≤ 10 x 109/L in period 3. Clinically significant bleeding was defined as WHO grade ≥ 2 bleeding. We used generalized estimating equations (GEE) to compare the frequency of clinically significant bleeding and platelet transfusions by study period, adjusting for age, sex, cancer type, chemotherapy, baseline platelet count, and baseline hemoglobin. RESULTS: Overall, 188 patients were enrolled. The median age was 22 years (range 1-80). Platelet transfusions were given to 42% of patients in period 1, 55% in period 2, and 45% in period 3. These transfusions occurred on 8% of days in period 1, 12% in period 2, and 8% in period 3. In adjusted models, period 3 had significantly fewer transfusions than period 1 (RR = 0.6, 95% CI 0.4-0.9; p = 0.01) and period 2 (RR = 0.5, 95% CI 0.4-0.7; p<0.001). Eighteen patients (30%) had clinically significant bleeding on at least one day in period 1, 23 (30%) in period 2, and 15 (23%) in period 3. Clinically significant bleeding occurred on 8% of patient-days in period 1, 9% in period 2, and 5% in period 3 (adjusted p = 0.41). Thirteen (21%) patients died in period 1, 15 (22%) in period 2, and 11 (19%) in period 3 (adjusted p = 0.96). CONCLUSION: Lowering the threshold for platelet transfusion led to fewer transfusions and did not change the incidence of clinically significant bleeding or mortality, suggesting that a threshold of 10 x 109/L platelets, used in resource-rich countries, may be implemented as a safe level for transfusions in sub-Saharan Africa.

Prevalence and patterns of traumatic bone loss following open long bone fractures at Mulago Hospital.

INTRODUCTION: Significant traumatic bone loss in developed countries occurs in a high proportion of open fractures ranging from 11.4% to 40%. However, literature from developing countries such as Uganda scarcely documents the prevalence and patterns of traumatic bone loss. Direct trauma and iatrogenic factors have been associated with traumatic bone loss as possible etiologies. OBJECTIVE: The study was aimed at establishing the prevalence and patterns of traumatic bone loss following open long bone fractures, and identifying factors associated with traumatic bone loss among patients presenting to Mulago Hospital within 24 hours of sustaining the injury up to completion of the initial fracture debridement, reduction, and fixation. METHODOLOGY: It was a prospective cohort study conducted at Mulago Hospital. A total of 136 open long bone fractures were registered and physically examined for traumatic bone loss. Patients who consented were recruited consecutively to participate in the study. Data on the patients' sociodemographics and fracture patterns were collected using pretested questionnaires and analyzed using Stata version 12. RESULTS: From 123 patients, a total of 136 open long bone fractures were registered. The prevalence of traumatic bone loss following open long bone fractures was 26.5%. Of the 36 open long bone fractures with traumatic bone loss, the more common pattern (61.1%) was significant traumatic bone loss (≥ 2.5 cm long). Commercial motorcycle riders (22.0%) and traders (20.3%) were the most common occupations associated with open long bone fractures. Gunshot injuries were the leading cause of traumatic bone loss in open long bone fractures. CONCLUSION: Our setting has a high prevalence of traumatic bone loss among open long bone fractures with the majority occurring in Gustilo type IIIB injuries of the tibia. The likelihood of traumatic bone loss is higher in open fractures caused by gunshots.

The willingness of orthopaedic trauma patients in Uganda to accept financial loans following injury.

BACKGROUND: Early access to a monetary loan may mitigate some of the socioeconomic burden associated with surgical treatment and lost wages following injury. The primary objective of this study was to determine the willingness of orthopaedic trauma patients in Uganda to accept a formal financial loan shortly after their time of injury. METHODS: A consecutive sample of adult orthopaedic trauma patients admitted to Uganda's national referral hospital was included in the survey. The primary outcome was the self-reported willingness to accept a financial loan. Secondary outcomes included the preferred loan terms, fracture treatment costs, and the factors associated with loan willingness. RESULTS: Of the 40 respondents (mean age, 40 years; 58% male), the median annual income was $582 United States dollars (USD) (range: $0-$6720). Around 50% reported a willingness to accept a loan with any terms. Patients requested loans with a median principal of $500 USD and a median interest rate of 5% with 12 months to pay back. Patients had received loans with a median principal of $142 USD, an interest rate of 10%, and payback of 6 months. These received loans covered a mean of 63% of the treatment costs. Patients with higher median incomes ($857 USD vs $342 USD) were more willing to accept a loan. CONCLUSION: This study demonstrated a limited interest of orthopaedic trauma patients in Uganda to procure loans through formalized lending. This observed resistance must be overcome in future programs that rely on mechanisms such as conditional cash transfers or microfinancing to improve clinical and socioeconomic outcomes after injury.

Survey to Assess Knowledge and Reported Practices Regarding Blood Transfusion Among Cancer Physicians in Uganda.

PURPOSE: Optimal decision making regarding blood transfusion for patients with cancer requires appropriate knowledge of transfusion medicine among physicians. We assessed blood transfusion knowledge, attitudes, and reported practices among physicians working at Uganda Cancer Institute (UCI). MATERIALS AND METHODS: A cross-sectional self-administered survey of UCI physicians on their knowledge, attitudes, and practices regarding blood transfusion was conducted from June to September 2014. In consultation with transfusion medicine experts, 30 questions were developed, including 10 questions for each of the following three domains: knowledge, attitudes, and practices. For the knowledge domain, we created a knowledge score equal to the number of questions correctly answered out of 10. RESULTS: Of 31 physicians approached, 90% participated. The mean knowledge score was 5.3 (median, 5.5), and 32% correctly answered at least seven of 10 questions. Almost all (96%) understood the importance of proper patient identification before transfusion and indicated identification error as the most common cause of fatal transfusion reactions. More than 60% of physicians acknowledged they lacked knowledge and needed training in transfusion medicine. Most physicians reported sometimes changing their mind about whether to provide a patient with a transfusion on the basis of opinion of colleagues and sometimes administering unnecessary transfusions because of influence from others. CONCLUSION: Although UCI physicians have some basic knowledge in transfusion, most reported gaps in their knowledge, and all expressed a need for additional education in the basics of blood transfusion. Transfusion training and evidence-based guidelines are needed to reduce inappropriate transfusions and improve patient care. Greater understanding of peer influence in transfusion decision making is required.

Role of North-South Partnership in Trauma Management: Uganda Sustainable Trauma Orthopaedic Program.

Uganda, as do many low-middle income countries, has an overwhelming volume of orthopaedic trauma injuries. The Uganda Sustainable Trauma Orthopaedic Program (USTOP) is a partnership between the University of British Columbia, McMaster University and Makerere University that was initiated in 2007. The goal of the project is to reduce the disabilities that occur secondary to musculoskeletal trauma in Uganda. USTOP works with local collaborators to build orthopaedic trauma capacity through teaching, innovation, and research. USTOP has maintained a multidisciplinary approach to training, involving colleagues in anesthesia, nursing, rehabilitation, and sterile reprocessing. The project was initiated at the invitation of the Department of Orthopaedics at Makerere University and Mulago Hospital in Kampala. The project is a collaboration between Canadian and Ugandan orthopaedic surgeons and is driven by the needs identified by the Ugandan surgeons. The program has also worked with collaborators to develop several technologies aimed at reducing the cost of providing orthopaedic care without compromising quality. As orthopaedic trauma capacity in Uganda advances, USTOP strives to continually evolve and provide relevant support to colleagues in Uganda to ensure that changes result in sustainable improvements in patient care.

Degloving injuries with versus without underlying fracture in a sub-Saharan African tertiary hospital: a prospective observational study.

BACKGROUND: Degloving injuries are surgical conditions in which an extensive portion of skin and subcutaneous tissue is detached from the underlying fasciae, muscles, or bone surface. Frequently, there is an association of fracture underlying the degloved area. We aimed to compare the short-term outcomes of degloving injuries with and without underlying fracture. METHODS: A prospective cohort study was conducted. We recruited patients with degloving injuries, and followed them up for 30 days to assess the outcomes. We collected data on socio-demography, cause and mechanism of injury, presence of underlying fracture, presence of shock at admission, injury severity score, location and size of degloving injuries, their management, and short-term outcomes. There were two comparison groups of degloving injuries based on the presence or absence of underlying fracture. We analyzed the differences between the two groups by using Fisher exact test for categorical variables and Student's t test for continuous variables; p values < 0.05 were considered to be significant. Risk ratio was calculated for the short-term outcomes. RESULTS: There were 1.56% (n = 51) of degloving injuries among 3279 admitted trauma patients during the study period of 5 months; 1% (n = 33) with and 0.56% (n = 18) without underlying fracture. For the overall degloving injuries, male-female ratio was 2 and mean age was 28.8 years; they were caused by road traffic crashes in 84%, and resulted in shock at admission in 29%. In the group with underlying fracture, lower limbs were frequently affected in 45% (p = 0.0018); serial debridement and excision of the avulsed flap were the most performed surgical procedures in 22% (p = 0.0373) and 14% (p = 0.0425), respectively; this same group had 3.9 times increased risk of developing poor outcomes (mainly infections) after 30 days and longer hospital stay (26.52 ± 31.31 days, p = 0.0472). CONCLUSION: Degloving injuries with underlying fracture are frequent in the lower limbs, and have increased risk of poor short-term outcomes and longer hospital stay. We recommend an early plastic surgery review at admission of patients with degloving injuries with underlying fracture to improve the flap viability and reduce the infection risk.

Patient Blood Management: An International Perspective.

This article describes practices in patient blood management (PBM) in 4 countries on different continents that may provide insights for anesthesiologists and other physicians working in global settings. The article has its foundation in the proceedings of a session at the 2014 AABB annual meeting during which international experts from England, Uganda, China, and Brazil presented the programs and implementation strategies in PBM developed in their respective countries. To systematize the review and enhance the comparability between these countries on different continents, authors were requested to respond to the same set of 6 key questions with respect to their country's PBM program(s). Considerable variation exists between these country regions that is driven both by differences in health contexts and by disparities in resources. Comparing PBM strategies from low-, middle-, and high-income countries, as described in this article, allows them to learn bidirectionally from one another and to work toward implementing innovative and preferably evidence-based strategies for improvement. Sharing and distributing knowledge from such programs will ultimately also improve transfusion outcomes and patient safety.

The role of Ugandan District Hospital orthopedic units in the care of vulnerable road users: a cross-sectional study.

BACKGROUND: Musculoskeletal injuries are a common cause of morbidity after road traffic injury (RTI) in motorizing countries. District hospitals provide front-line orthopedic care in Uganda and other sub-Saharan African nations. Improving care at the district hospital level is an important component of the World Health Organization's strategy for surgical and trauma systems strengthening, but the data necessary to inform RTI safety and care initiatives has previously been insufficient at the district hospital level. The objective of this study was to provide data on the patient population and patterns of musculoskeletal injury caused by RTI at Ugandan district hospitals. METHODS: In this cross-sectional study, all patients with musculoskeletal injuries identified on x-ray presenting to three Ugandan district hospitals from October 2013 to January 2014 were interviewed and examined to obtain data on patient demographics and injury context by road user category. This manuscript is a sub-group analysis of RTI victims from a broader dataset of all musculoskeletal injuries. RESULTS: Vulnerable road users comprised 92 % of musculoskeletal RTI patients, with 49 % (95 % CI 41-57 %) pedestrians, 41 % (95 % CI 33-49 %) motorcyclists, and 2 % (95 % CI 0-4 %) cyclists. Commonly injured subgroups included student pedestrians (33 % (95 % CI 22-44 %) of pedestrians) and motorcyclists with less than a post-secondary education (74 % (95 % CI 63-85 %) of motorcyclists). The morning hours were the most common time of injury for all RTI patients (37 %%; 95 % CI 30-44 %) and motorcyclists (46 %; 95 % CI 34-58 %), while pedestrians were most commonly injured in the evening (32 %; 95 % CI 21-43 %). CONCLUSIONS: By demonstrating commonly injured demographic groups and high frequency times of day for injury, this surveillance study of musculoskeletal RTI suggests targeted avenues for future road safety research in the districts of Uganda. Compared with previous studies from the capital of Uganda, these results suggest that Ugandan district hospitals care for a disproportionate share of vulnerable road users, a discrepancy which may pertain to other sub-Saharan African nations, as well. Strengthening district hospital orthopedic care should be considered a priority of strategies aimed at improving outcomes for these vulnerable groups.

Seeking health care from a general hospital in Uganda following a fracture or a dislocation.

INTRODUCTION: Selecting a treatment approach and a facility to get treated from, poses a challenge in musculoskeletal injuries in Africa. The study aimed at determining demographic and injury characteristics of patients with musculoskeletal injuries and how these impact the time and reason for presenting to a general hospital in Uganda. METHODS: An observational study was carried out at Entebbe general hospital on patients presenting with musculoskeletal injuries between 1 November 2014 and 28 February 2015. The patient demographics, injury characteristics, duration of injury to presentation for treatment and reason for seeking treatment from this hospital were noted. RESULTS: A total of 101 patients were recruited. Of these, 95 had fractures while six had dislocations. Patients took an average of 96 h before presenting for care, females taking significantly longer than males (191.2 and 58.6 h respectively, p = 0.005). The fractured segment of bone significantly influenced the patients' choice for care at this hospital (p = 0.02). DISCUSSION: Entebbe General Hospital serves a young and unemployed population for musculoskeletal injuries. These patients present late for care, especially females. Patients base their choice for care from this hospital on the character of the injury.

INTRODUCTION: La sélection d'une approche de traitement et d'un établissement où l'on peut se faire soigner pose un problème en matière de lésions musculosquelettiques en Afrique. L'étude visait à déterminer les caractéristiques démographiques et des blessures des patients atteints de lésions musculosquelettiques et leur incidence sur le délai et le motif de la consultation dans un hôpital général en Ouganda. MÉTHODES: Une étude d'observation a été effectuée à l'hôpital général d'Entebbe sur des patients présentant des lésions musculosquelettiques entre le 1er novembre 2014 et le 28 février 2015. Les données démographiques des patients, les caractéristiques des blessures, le délai entre la blessure et la consultation en vue de se faire traiter, et le motif de la recherche de traitement auprès cet hôpital ont été enregistrés. RÉSULTATS: Au total, 101 patients ont été étudiés. Parmi ceux-ci, 95 souffraient de fractures alors que 6 souffraient de luxations. Les patients ont mis en moyenne 96 heures à consulter pour se faire soigner, les femmes prenant bien plus de temps que les hommes (191,2 et 58,6 heures respectivement, p = 0,005). Le segment fracturé de l'os a influencé de façon significative le choix des patients de se faire soigner dans cet hôpital (p = 0,02). DISCUSSION: L'hôpital général d'Entebbe a pour patients une population jeune et sans emploi en ce qui concerne les lésions musculosquelettiques. Ceux-ci se présentent de façon tardive pour obtenir des soins, en particulier les femmes. Les patients fondent leur choix de prise en charge par cet hôpital en fonction de la nature de la blessure.

Profiles of blood and blood component transfusion recipients in Zimbabwe.

BACKGROUND: There are limited published data on the characteristics of blood transfusion recipients in sub-Saharan Africa. This study describes the demographic characteristics of blood transfusion recipients and patterns of blood and blood component use in Zimbabwe. MATERIALS AND METHODS: Data on the characteristics of the blood transfusion recipients (age, sex, blood group), blood components received (type, quantity), discharge diagnoses and outcomes following transfusion (discharge status, duration of stay in hospital), were retrospectively collected from four major hospitals for the period from January 1, 2012 to December 31, 2012. Diagnoses were grouped into broad categories according to the disease headings of the International Classification of Diseases (ICD-10). Surgical procedures were grouped into broad categories according to organ system using ICD-9. RESULTS: Most of the 1,793 transfusion recipients studied were female (63.2%) and in the reproductive age group, i.e. 15-49 years (65.3%). The median age of the recipients was 33 years (range, 0-93). The majority of these recipients (n=1,642; 91.6%) received a red blood cell transfusion. The majority of the patients were diagnosed with conditions related to pregnancy and childbirth (22.3%), and diseases of blood and blood-forming organs (17.7%). The median time spent in hospital was 8 days (range, 0-214) and in-hospital mortality was 15.4%. DISCUSSION: Our sample of blood transfusion recipients were fairly young and most of them received red blood cell transfusions. The majority of patients in the reproductive age group received blood transfusions for pregnancy and childbirth-related diagnoses.

Transfusion Medicine in Sub-Saharan Africa: Conference Summary.

In November 2014, a 3-day conference devoted to transfusion medicine in sub-Saharan Africa was held in Kampala, Uganda. Faculty from academic institutions in Uganda provided a broad overview of issues pertinent to transfusion medicine in Africa. The conference consisted of lectures, demonstrations, and discussions followed by 5 small group workshops held at the Uganda Blood Transfusion Service Laboratories, the Ugandan Cancer Institute, and the Mulago National Referral Hospital. Highlighted topics included the challenges posed by increasing clinical demands for blood, the need for better patient identification at the time of transfusion, inadequate application of the antiglobulin reagent during pretransfusion testing, concern regarding proper recognition and evaluation of transfusion reactions, the expanded role for nurse leadership as a means to improve patient outcomes, and the need for an epidemiologic map of blood usage in Africa. Specialty areas of focus included the potential for broader application of transcranial Doppler and hydroxyurea therapy in sickle cell disease, African-specific guidelines for transfusion support of cancer patients, the challenges of transfusion support in trauma, and the importance of African-centered clinical research in pediatric and obstetric transfusion medicine. The course concluded by summarizing the benefits derived from an organized quality program that extended from the donor to the recipient. As an educational tool, the slide-audio presentation of the lectures will be made freely available at the International Society of Blood Transfusion Academy Web site: http://www.isbtweb.org/academy/.

Blood utilization at a national referral hospital in sub-Saharan Africa.

BACKGROUND: A safe and adequate supply of blood is critical to improving health care systems in sub-Saharan Africa, where little is known about the current use of blood. The aim of this study was to comprehensively describe the use of blood at a tertiary care hospital to inform future efforts to strengthen blood programs in resource-limited settings. STUDY DESIGN AND METHODS: Data were collected from blood bank documentation for all units issued at Mulago Hospital Complex in Kampala, Uganda, from mid-January to mid-April 2014. RESULTS: A total of 6330 units (69% whole blood, 32% red blood cells, 6% platelets, 2% plasma) were issued over the 3-month study period to 3662 unique patients. Transfusion recipients were 58% female and median age was 27 years (interquartile range [IQR], 14-41). Median pretransfusion hemoglobin was 5.6 g/dL (IQR, 4.0-7.2 g/dL, n = 1090). Strikingly, cancer was the top indication for transfusion (33.5%), followed by pregnancy-related complications (12.4%) and sickle cell disease (6.9%). CONCLUSION: This study provides a comprehensive picture of blood use at a national referral hospital in sub-Saharan Africa. Noncommunicable diseases, particularly oncologic conditions, represent a large proportion of demand for transfusion services.

Informed consent in blood transfusion: knowledge and administrative issues in Uganda hospitals.

Blood as a transplant is not free of risks. Clinicians and patients ought to know the parameters of a transfusion informed consent. A mixed methodology to explore patients' and clinicians' knowledge and opinions of administration and strategies to improve the transfusion informed consent process was conducted. The clinicians' level of knowledge was limited to provision of information about and the right to consent to a transfusion. They disagreed on administrative issues but had acceptable opinions on improving the process. Patients perceived this process as a way of assurance of blood safety. This process is important and should not be omitted.