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Background Thorough and standardized documentation of operative notes is essential for effective communication, patient safety, legal protection, and the continuity of care. However, in many hospitals in Sudan, surgeons often use non-standardized methods, resulting in inconsistent and incomplete records. This study evaluates the quality of operative notes at the Port Sudan Teaching Hospital using the Royal College of Surgeons of England (RCSEng) guidelines, aiming to improve compliance and documentation practices. Methods A clinical audit was conducted in two cycles at the General Surgery Department. The first cycle, a retrospective review of 50 surgical notes, was carried out over one week in July 2024. The second cycle conducted prospectively on another 50 notes throughout September 2024, involved the implementation of an improved proforma and staff training. Data were collected using a standardized checklist aligned with Royal College of Surgeons in Ireland (RCSI) guidelines, covering 18 documentation criteria. Results were analyzed using Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington, United States) to assess improvements in compliance. Results The compliance with documentation standards increased significantly from 51.9% in the first cycle to 82.1% in the second cycle. Notable improvements were observed in recording operative findings (17, 34%), complications (34, 68%), and deep vein thrombosis (DVT) prophylaxis (47, 94%). Despite the overall progress, modest improvements were noted in documenting the anesthetist's name (2.5, 5%) and the surgeon's signature (3, 6%). These findings underscore the positive impact of structured proformas and targeted staff training. Conclusion The implementation of standardized documentation tools and staff training significantly improved the quality of surgical operative notes at the Port Sudan Teaching Hospital. While notable progress was achieved, continued efforts, including digital solutions and regular audits, are needed to sustain these improvements and promote patient safety.

The transfusion quality improvement project (QIP) serves as a valuable tool for assessing and educating individuals who request blood components. The World Health Organization (WHO) recommends that each institution utilize a blood transfusion request form to ensure the effective conveyance of patient information to the hospital's blood bank. This QIP aimed to implement a transfusion request form and measure compliance with its use. A prospective study was conducted at Al Managil Teaching Hospital, Sudan, from May 1 to August 3, 2024, to address the lack of standardized transfusion request forms. The study included three cycles involving pre-intervention analysis, two phases of intervention with training sessions, and post-intervention evaluations. The interventions focused on developing and implementing a new transfusion request form, training clinical physicians, and reinforcing the form's use. Data from 100 randomly selected transfusion request forms were analyzed for completeness and adherence. The study showed significant improvements in the completeness of transfusion request forms across three cycles. In the first cycle, no data were collected, highlighting the absence of standardized forms. During the second cycle, with the introduction of the new form, the completion rates varied: some fields, such as patient information and clinical details, were fully completed in 50 cases (100%), while critical clinical parameters, such as current hemoglobin (Hb) and platelet (PLT) levels, were completed in only four requests (8%). By the third cycle, there was a substantial increase in completion rates across all domains. For example, patient information fields achieved 100% completion in 50 cases, and clinical parameters saw significant improvement, with current Hb and PLT levels documented in 48 cases (96%). The mean percentage completion increased from 68.1% in the second cycle to 97.9% in the third cycle, demonstrating the effectiveness of the interventions and training sessions. Minor decreases were observed in health insurance documentation and certain clinical details, indicating areas for further improvement. The systematic implementation and iterative evaluation of transfusion request forms significantly enhanced documentation completeness.