In South Africa, blood and blood products are critical yet limited resources, with only 1% of the population actively donating. Despite their scarcity, blood products are frequently administered in hospitals. Issues of mismanagement, including inadequate informed consent, waste and improper transfusions, have a multi-factorial negative impact on health services. Intern doctors who regularly make transfusion decisions from the outset of their medical careers often lack sufficient knowledge, contributing to these challenges. Given the inherent risks of blood transfusions, it is essential for physicians to have a thorough understanding of potential complications to ensure informed consent, optimal patient care and appropriate resource management.
Aim
This study aims to assess intern doctors’ knowledge of transfusion medicine, identifying gaps in their understanding and highlighting areas for improvement in education and practice.
Setting
Port Elizabeth intern complex, Eastern Cape, South Africa.
Methods
A validated exam with 20 questions was distributed to all interns within the Port Elizabeth intern complex. The exam assessed the transfusion medicine knowledge of intern doctors within the complex.
Results
The survey was completed by 87 intern doctors over four sites within the Port Elizabeth intern complex. An overall median score of 33% (standard error [s.e.] 1) was obtained by the participants. The category of the questionnaire that was answered poorly was transfusion reactions, with a median of 14.3%, and the categories that demonstrated better scores were transfusion thresholds and safe administration of blood products.
Conclusion
Intern doctors across the Port Elizabeth intern complex demonstrated inadequate transfusion medicine knowledge, especially relating to transfusion reactions. These findings require attention and action to improve our healthcare service.
Contribution
This study identifies significant gaps in intern doctors’ transfusion medicine knowledge, particularly regarding transfusion reactions, with implications for patient safety and resource use. It supports the need for targeted education to improve clinical practice. These findings align with the goals of anaesthetists, as safe and effective transfusion practice is central to perioperative and critical care within anaesthesia.
transfusion medicineinternknowledgeblood transfusion, blood productBEST testFunding information This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.Introduction
Blood is a precious and limited resource in South Africa, where constant alerts about critically low blood bank levels and urgent appeals for public donations are common. The availability of blood is crucial in our healthcare system as it often serves as a life-saving treatment.
To administer blood products effectively, clinicians must make patient-centred decisions, considering a risk–benefit analysis in the context of individual patients.1 Additional factors, such as product shelf life, availability and consent, need to be considered to ensure the rational use of transfusions. Insufficient knowledge of transfusion medicine among those ordering and administering blood products can have devastating consequences for various aspects of healthcare.
The worldwide concern for the rational use of blood is ever increasing and has led to initiatives like the World Health Organization’s Patient Blood Management Initiative in 2010.2 One of the primary aims of this initiative is promoting evidence-based transfusion practices, which form the foundation of transfusion medicine knowledge and have been notably successful in Australia. Adequate knowledge of transfusion medicine is essential to the successful implementation of patient blood management principles.
A review of the literature revealed a deficiency in transfusion medicine knowledge among doctors at various stages of their training.3,4,5,6,7,8,9,10,11,12,13,14,15
In the resource-constrained environment of South African hospitals, there are large demands placed on intern doctors. These junior doctors are often relied on to make transfusion decisions, obtaining consent, ordering blood or blood products and monitoring patients during blood transfusions. A knowledge gap within this group of doctors has far-reaching implications, affecting blood availability, ethical and clinical patient care, adverse event outcomes, hospitalisation durations and financial considerations, among other aspects.
Intern doctors are recent medical school graduates who are frequently entrusted with treatment decisions independently, without the guidance of more experienced physicians. Assessing the level of knowledge within this group facilitates the development of future training programmes and uncovers modifiable factors contributing to inappropriate blood management.
Transfusion medicine encompasses a broad spectrum of topics, including transfusion triggers, indications and contraindications for transfusions, side effects and adverse events associated with blood products, ethical considerations and consent procedures for blood products, as well as correct dosing when administering these products.
By assessing the transfusion medicine knowledge of interns, educational needs were identified and training programmes can be customised accordingly. Employing a validated, standardised assessment tool allows for ongoing evaluations to gauge the effectiveness of training initiatives.
Research methods and designParticipants
All interns working in the Port Elizabeth intern complex were invited to fill in the online Bio-medical Excellence for Safer Transfusions (BEST) test questionnaire over a 4-week period.
Survey administration software, Google Forms, was used to gather the information online. It was introduced at an intern meeting and thereafter sent via WhatsApp to all interns rotating in the complex. Participation was voluntary and anonymous. Participants were urged not to use other sources to answer the questionnaire, and there was no time limit set. They could return to questions until the questionnaire was submitted, and after that it was not assessable. Answers were not discussed to discourage interference with results in other groups.
Assessment questionnaire
Intern knowledge was assessed by the Biomedical Excellence for Safer Transfusion (BEST) test. This is a validated questionnaire compiled of 20 questions.16 Multiple-choice questions were generated by the BEST Collaborative as well as the American Society of Clinical Pathology.
This assessment tool consists of 20 single-best answer multiple-choice questions on transfusion topics. Exam topics were determined by a modified Delphi method.15 Mean scores of 42%, 62% and 82% were obtained by non-expert doctors who were expected to have basic, intermediate and expert levels of transfusion medicine knowledge, respectively.
Statistical analysis
The primary outcome of the study was the mean scores of the BEST test in this group. Secondary outcomes of the study compared the various subsections of the BEST test to identify areas of knowledge deficit.
Results were expressed as frequencies and percentages for categorical variables. Only fully completed forms were included. Descriptive statistics were used in our study to summarise central tendency, dispersion and distribution of quantitative variables. We used measurements such as median, standard deviation (s.d.) and range to provide insight into the characteristics of the data set.
Data transformation was applied to the qualitative variables to achieve normality and stabilise the variance, especially in the skewed data. The Kolmogorov-Smirnov and Shapiro-Wilks tests were used to determine mean score normality. As all tests of normality were significant, nonparametric tests were used for all subsequent comparisons. The median scores of the categories for the total group were compared using nonparametric analyses as the data were shown not to be normal.
Furthermore, correlation analysis was utilised to examine the relationship between two or more quantitative variables. The normality tests were significant, leading to a nonparametric test being used for comparisons. Comparison of median scores of the four subgroups for all the respondents was done with the Friedman analysis of variance (ANOVA) test for related groups.
The Wilcoxon matched-pairs tests were computed on the subscale pairs to demonstrate any differences between categories.
Analysis was performed using the TIBCO® Statistica computer software (TIBCO Software Inc. [2020] Statistica, version 14.0, Palo Alto, CA, United States [US]; https://www.tibco.com/).
Ethical considerations
Ethical clearance to conduct this study was obtained from the Walter Sisulu University Faculty of Health Sciences Research Ethics Committee (No. 144/2022).
ResultsDemographics of intern doctor participants
A total of 87 intern doctor responses were received from four sites over a 4-week period. This represents a 48% response rate. The sample included intern doctors in both first and second years of internship. Table 1 demonstrates the demographic data of the participants. Most of the participants were first-year interns (62%).
Summary of demographic information and response rates (N = 87).
Factor
Category
n
%
Hospital currently stationed
-
-
-
Livingston Hospital
30
34
Dora Ngiza Hospital
37
43
Uitenhage Provincial Hospital
17
20
Elizabeth Donkin Psychiatric Hospital
2
2
Missing
1
1
Year of internship
-
-
-
1st
54
62
2nd
33
38
Department rotating in
-
-
-
Anaesthesia
8
9
Family Medicine
11
13
General Surgery
16
18
Internal Medicine
10
11
Obstetrics
16
18
Orthopaedics
4
5
Paediatrics
16
18
Psychiatry
6
7
Bio-medical Excellence for Safer Transfusion test results
The 20-question questionnaire to assess the objective knowledge of transfusion medicine achieved an overall mean score of 33%, with individual intern scores ranging from 15% to 65% as reflected in Table 2. The category of the questionnaire that was answered the most poorly was transfusion reactions, with a median of 14.3% and a range of 0% – 71%. The categories that demonstrated better scores were transfusion thresholds and safe administration of blood products (Table 2).
Correct responses per category.
Category
Number of items
% Correct responses
Median (%)
s.e. (%)
Range
Transfusion threshold
7
41
42.2
1.7
14–71
Transfusion reaction
7
22
14.3
1.5
0–71
Safe administration
3
52
52.5
2.8
0–100
Other
3
19
18.8
2.1
0–67
Total
20
33
32.6
1.0
15–65
s.e., standard error.
The questions were grouped into the four categories of Transfusion threshold, Transfusion reaction, Safe administration and Other. The percentage of correct responses to the questions in these categories is presented in Table 2. The categories of the questionnaire that were answered the most poorly were transfusion reactions with a median of 14.3% and other with a median of 18.8%. The categories that demonstrated better scores were transfusion thresholds and safe administration of blood products, with 52% and 41% correct responses, respectively.
Overall, a third of the responses to all the questions were correct. The Wilcoxon matched-pairs tests computed on the subscale pairs (Table 2) show significant differences within each pair, apart from the medians of the seven transfusion reaction items vs the three items categorised in the category Other.
Based on the median scores (Table 2), the three questions on safe administration were considered the least difficult (Me = 67% correct), followed by the seven questions on transfusion thresholds (Me = 43% correct) and thereafter the other items.
The 20 questions of the BEST questionnaire are presented in Figure 1 by topic. The items are ranked by difficulty (correct responses).
Scores of the best test by topic (N = 87).
The correct responses per question range from 0% to 80%. No participants answered the Transfusion-Related Acute Lung Injury (TRALI) prevention question correctly (question 20).
Questions relating to red blood cell (RBC) transfusion, acute haemolytic transfusion reaction, reporting transfusion reaction and infectious disease risk were answered correctly at least 70% of the time. Most participants (80%) answered the question on acute haemolytic transfusion reaction correctly.
Discussion
In this study, a well-developed and validated questionnaire was used to assess the knowledge of transfusion medicine in a group of intern doctors at the Port Elizabeth intern complex. The study’s mean score of 33% on the modified BEST test questionnaire starkly contrasts with the expected scores observed in the pilot study using the same assessment tool. In the pilot study, basic knowledge scored 42%, intermediate at 62%, and expert level at 82%.16 This scale has guided all subsequent BEST test studies.9,17,18,19 This significant disparity suggests that interns at the Port Elizabeth Hospital Complex scored poorly compared to expectations. While new practitioners like intern doctors may be expected to have a basic knowledge of transfusion medicine, an intermediate level may even be expected. Therefore, the findings highlighted concerning deficiencies in interns’ transfusion medicine knowledge compared to established benchmarks.
The observed significant differences in all category comparisons, except for transfusion thresholds versus safe administration and transfusion reactions versus other, highlight variations in interns’ understanding across different aspects of transfusion medicine. Specifically, interns found transfusion threshold and safe administration questions relatively easier to answer compared to questions on transfusion reactions and other aspects. This underscores the need for targeted educational interventions to address knowledge gaps effectively and ensure comprehensive coverage of all essential transfusion medicine concepts.
The study’s findings underscored the critical importance of addressing knowledge deficits, particularly in areas such as transfusion reactions. By tailoring educational interventions to target this specific area of weakness, one can improve patient care outcomes and enhance the quality of transfusion medicine practices within our healthcare setting. These interventions should aim to equip interns with the necessary knowledge and skills to confidently manage transfusion-related scenarios and ensure optimal patient care.
The study’s findings aligned with the existing literature on transfusion medicine knowledge, indicating a global deficit in this area among healthcare professionals. By contributing new insights into interns’ knowledge levels and highlighting specific areas of weakness, this study has laid the groundwork for further research and improvement in transfusion medicine education and practices. Additionally, our findings provided valuable insights that can inform the development of targeted clinical and educational interventions aimed at addressing knowledge gaps and improving safety in transfusion practices.
This study was conducted in the unique context of the Port Elizabeth intern complex in the Eastern Cape. This allows for tailored educational strategies to be developed, which are relevant and feasible within the local healthcare setting. Further practical implications for healthcare administrators, educators and policy makers, highlighting the need for comprehensive transfusion medicine training programmes and ongoing support mechanisms for intern doctors.
Addressing the gaps will lead to enhanced patient safety, as well as contributing to the professional development and confidence of the intern doctors.
Study limitations
The study has several limitations. While the survey used a validated international questionnaire, some questions may not be fully applicable in the African context. The electronic format allowed participants to look up answers if they so wished. The study’s location in Port Elizabeth limits the generalisability of the findings to the broader Eastern Cape, where transfusion medicine practices and educational resources may differ. The study focused on interns’ knowledge but did not assess their clinical practices, which could differ from theoretical knowledge.
Conclusion
In summary, we have demonstrated poor transfusion medicine knowledge in the intern group at the Port Elizabeth intern complex, particularly relating to transfusion reactions. Considering the poor performance, we advocate for improving intern training in transfusion medicine with re-assessments not just locally but also nationally.
Acknowledgements
The author would like to express their heartfelt gratitude to their supervisor, Dr Lorenzo Boretti, a distinguished senior consultant in the Department of Anaesthesia at Livingstone Hospital. Dr Boretti’s unwavering guidance and support were invaluable during the entire process of my Master of Medicine (MMed) research component. His expertise and dedication have been instrumental in shaping their academic journey, and for that, the author is truly thankful. The author is truly fortunate to have had the support and guidance of such esteemed individuals throughout my academic journey.
The author extend their deepest appreciation to their parents for their unwavering support and encouragement throughout this challenging endeavour. Their belief in me and their sacrifices made those long hours of work bearable, and is forever grateful for their love and encouragement.
The author would like to extend my thanks to Dr Merle Werbeloff, the statistics consultant. Dr Merle provided invaluable assistance with statistical insights that significantly enhanced the quality and reliability of their research. Her expertise and commitment to excellence have been pivotal in achieving the research’s objectives, and is deeply appreciative of her contributions.
This article is based on research originally conducted as part of Monique Marwick’s master’s thesis titled ‘Knowledge of blood products usage among intern doctors: A cross-sectional study in an Eastern Cape tertiary hospital’, submitted to the Faculty of Medicine and Health Sciences, Department of Anaesthesiology, Walter Sisulu University in 2025. The thesis was supervised by Lorenzo Borretti. The thesis was reworked, revised, and adapted into a journal article for publication. The original thesis is currently unpublished and was not publicly available online at the time of publishing this article but available from the author, Monique Marwick.
Competing interest
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
CRediT authorship contribution
Monique Marwick: Conceptualisation, Methodology, Formal analysis, Investigation, Writing – original draft, Visualisation, Project administration, Software, Validation, Data curation, Resources, Writing – review & editing. Lorenzo Boretti: Conceptualisation, Methodology, Formal analysis, Investigation, Visualisation, Project administration, Software, Validation, Data curation, Writing – review & editing, Supervision. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.
Data availability
Data sharing is not applicable to this article as no new data were created or analysed in this study.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
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How to cite this article: Marwick M, Boretti L. Assessing intern doctors’ knowledge of transfusion medicine: A survey. South Afr J Anaesth Analg. 2026;32(1), a1555. https://doi.org/10.4102/sajaa.v32i1.1555