Purpose. To improve the reliability of the transfusion processTo achieve this through standardisationDocumentationProcess . Background. 120,748 blood components issued by Welsh Blood Service 2006-2007 Adverse events due to transfusion process errorsRange of transfusion charts and forms througho
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1. Addressing Patient Safety in Transfusion: standardising documentation Maria Cheadle
Better Blood Transfusion Team
2. Purpose To improve the reliability of the transfusion process
To achieve this through standardisation
3. Background 120,748 blood components issued by Welsh Blood Service 2006-2007
Adverse events due to transfusion process errors
Range of transfusion charts and forms throughout Wales
All-Wales drug chart in use
All-Wales anticoagulant chart being developed
5. Lack of understanding of what a bedside check involves, and why
A 67-year old female patient in a side room was prescribed a transfusion. A trained housekeeper took the correct patient documentation to the issue fridge, but collected a unit of blood for a different patient with the same first and last name.
The unit was checked outside the side room, against the compatibility statement, by two nurses. The transfusion record was completed by both nurses indicating that all checks had been completed. One nurse then entered the room and administered the blood without a bedside ID check.
The patient was group O RhD positive and received a unit of A RhD positive red cells.
The already severely ill patient developed respiratory problems and died later that day, though there was no record of haemolysis.
6. Background Lack of understanding of the reasoning behind the decision making process in transfusion
Underpinning knowledge and familiarity with transfusion protocols absent
Worrying disregard for protocol and an offhand attitude to bedside checking
Patients receiving blood without prescription
Patients with no identification receiving components
Prescription based on incorrect results or poor/absent clinical reasoning
8. Background SHOT 2007 – general recommendations
junior doctors’ education
qualified, trained and competent staff to be responsible for transfusion safety
laboratory and clinical area
Junior doctors’ dynamic training process
exposure to a wide and varied range of documentation
National Comparative Audits (2003, 2005, 2008)
transfusion episodes often poorly documented
9. Fundamental Principles
10. The problem… WBS BBT recognised need to standardise documentation as a priority
Aim - Improve the safety and quality of transfusion practice
Opportunity to link to1000 lives campaign
Endorsed by WAG Clinical Advisory Group and Medical Directors of all Welsh Trusts
11. Project goals To standardize the underpinning processes associated with the transfusion process through the development of an All-Wales blood transfusion request form and transfusion record
To achieve 95% reliability in documentation correctness and completeness associated with the transfusion process (proxy measure for understanding and complying with the process)
12. Project Measures Process Measures
% completion of documentation (initially stratified into different elements to target improvement)
Staff satisfaction with the request form and transfusion record (e.g. time to complete, relevance of component parts of form, perception about added safety)
‘days between’ adverse incidents (may be stratified into transient, permanent or fatal)
13. Documents already in use
Is it all necessary?
How will we know?
Who can help us?
14. Our journey….. Destination
- standardised transfusion documentation in use across Wales
- 1000 lives campaign and PDSA
17. Plan Two standardised documents were developed for trial - transfusion record and transfusion request form
18. Do One staff member, one patient, one form
Documents sequentially trialled in a range of clinical areas and the transfusion laboratory to demonstrate that they were fit for purpose
20. Study Parts not completed
User feedback essential – engage with staff
Ownership of document
21. Chart showing number and % of completed data items on blood transfusion request forms
22. Results 2 standardised documents
Fit for purpose
Make what is right to do easy to do
Reliability from being guided through the process
23. Challenges Enthusiasts
Willing but not enthusiastic
Resistance to change
Reluctance to give up bits important to them
24. Lessons learnt Start small – minimum resources
Select an area where staff are willing
Engage big users early on – need ownership
Testing in different conditions is essential
Good leadership and clinical engagement is essential
25. Lessons learnt (2) Opportunity to challenge obsolete custom and practice
Keep people engaged
Be prepared for a progress dip
Benefits of joining with 1000 Lives
Co-opt expert help – use it!
26. Future developments Real-time measurement of reduction in transfusion errors
Impact of national guidelines, advice etc.
Inclusion of bedside tracking
27. Finished article?