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Addressing Patient Safety Addressing Patient Safety in Transfusion: in Transfusion: standardising standardising

documentationdocumentation

Maria CheadleMaria Cheadle

Karen ShreeveKaren Shreeve

Better Blood Transfusion TeamBetter Blood Transfusion Team

Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service

PurposePurpose To improve the reliability of the To improve the reliability of the

transfusion processtransfusion process To achieve this through To achieve this through

standardisationstandardisation−DocumentationDocumentation−Process Process


BackgroundBackground 120,748 blood components issued 120,748 blood components issued

by Welsh Blood Service 2006-2007 by Welsh Blood Service 2006-2007 Adverse events due to transfusion Adverse events due to transfusion

process errorsprocess errors Range of transfusion charts and Range of transfusion charts and

forms throughout Wales forms throughout Wales StandardisationStandardisation

−All-Wales drug chart in useAll-Wales drug chart in use−All-Wales anticoagulant chart being All-Wales anticoagulant chart being

developeddeveloped


BackgroundBackground

SHOT Annual Reports


Lack of understanding of what a bedside check Lack of understanding of what a bedside check involves, and whyinvolves, and why

A 67-year old female patient in a side room was prescribed a A 67-year old female patient in a side room was prescribed a transfusion. A trained housekeeper took the correct patient transfusion. A trained housekeeper took the correct patient documentation to the issue fridge, but collected a unit of documentation to the issue fridge, but collected a unit of blood for a different patient with the same first and last blood for a different patient with the same first and last name.name.

The unit was checked outside the side room, against the The unit was checked outside the side room, against the compatibility statement, by two nurses. The transfusion compatibility statement, by two nurses. The transfusion record was completed by both nurses indicating that all record was completed by both nurses indicating that all checks had been completed. One nurse then entered the checks had been completed. One nurse then entered the room and administered the blood without a bedside ID check.room and administered the blood without a bedside ID check.

The patient was group O RhD positive and received a unit of The patient was group O RhD positive and received a unit of A RhD positive red cells.A RhD positive red cells.

The already severely ill patient developed respiratory The already severely ill patient developed respiratory problems and died later that day, though there was no problems and died later that day, though there was no record of haemolysis.record of haemolysis.


BackgroundBackground Lack of understanding of the reasoning behind Lack of understanding of the reasoning behind

the decision making process in transfusionthe decision making process in transfusion Underpinning knowledge and familiarity with Underpinning knowledge and familiarity with

transfusion protocols absenttransfusion protocols absent Process failures Process failures Worrying disregard for protocol and an offhand Worrying disregard for protocol and an offhand

attitude to bedside checkingattitude to bedside checking Patients receiving blood without prescriptionPatients receiving blood without prescription Patients with no identification receiving Patients with no identification receiving

componentscomponents Prescription based on incorrect results or Prescription based on incorrect results or

poor/absent clinical reasoningpoor/absent clinical reasoning


BackgroundBackground

““If qualified, educated and If qualified, educated and competent staff take full competent staff take full responsibility for ensuring patient responsibility for ensuring patient safety, the type of cases safety, the type of cases described…..could be consigned to described…..could be consigned to history.” (SHOT, 2007)history.” (SHOT, 2007)


BackgroundBackground SHOT 2007 – general recommendationsSHOT 2007 – general recommendations

− junior doctors’ educationjunior doctors’ education−qualified, trained and competent staff to be qualified, trained and competent staff to be

responsible for transfusion safetyresponsible for transfusion safety− laboratory and clinical arealaboratory and clinical area

Junior doctors’ dynamic training processJunior doctors’ dynamic training process−exposure to a wide and varied range of exposure to a wide and varied range of

documentationdocumentation National Comparative Audits National Comparative Audits

(2003, 2005, 2008)(2003, 2005, 2008)− transfusion episodes often poorly transfusion episodes often poorly

documenteddocumented


Fundamental PrinciplesFundamental Principles

Documentation Communication

Identification

SafeTransfusion


The problem…The problem… WBS BBT recognised need to WBS BBT recognised need to

standardise documentation as a priority standardise documentation as a priority

Aim - Improve the safety and quality of Aim - Improve the safety and quality of transfusion practice transfusion practice

Opportunity to link toOpportunity to link to1000 lives 1000 lives campaigncampaign

Endorsed by WAG Clinical Advisory Endorsed by WAG Clinical Advisory Group and Medical Directors of all Group and Medical Directors of all Welsh TrustsWelsh Trusts


Project goalsProject goals To standardize the underpinning processes To standardize the underpinning processes

associated with the transfusion process through associated with the transfusion process through the development of an All-Wales blood the development of an All-Wales blood transfusion request form and transfusion recordtransfusion request form and transfusion record

To achieve 95% reliability in documentation To achieve 95% reliability in documentation correctness and completeness associated with correctness and completeness associated with the transfusion process (proxy measure for the transfusion process (proxy measure for understanding and complying with the process)understanding and complying with the process)


Project MeasuresProject Measures Process MeasuresProcess Measures

−% completion of documentation (initially % completion of documentation (initially stratified into different elements to target stratified into different elements to target improvement) improvement)

Balancing MeasureBalancing Measure−Staff satisfaction with the request form and Staff satisfaction with the request form and

transfusion record (e.g. time to complete, transfusion record (e.g. time to complete, relevance of component parts of form, relevance of component parts of form, perception about added safety)perception about added safety)

Outcome MeasureOutcome Measure−‘‘days between’ adverse incidents (may be days between’ adverse incidents (may be

stratified into transient, permanent or fatal)stratified into transient, permanent or fatal)


Documents already in Documents already in useuse

Is it all necessary?Is it all necessary?

How will we know?How will we know?

Who can help us?Who can help us?


Our journey…..Our journey…..

DestinationDestination

- standardised transfusion - standardised transfusion documentation in use across documentation in use across WalesWales

VehicleVehicle

- 1000 lives campaign and PDSA- 1000 lives campaign and PDSA


PDSA?PDSA?


Plan

Do

Act

Study

What are we trying

to accomplish?

How will we know

that a change is an

improvement?

What changes can we

make that will result

in improvement?

Step 1: Plan Plan the test or

observation, including a plan for collecting

data

Step 3: StudySet aside time to

analyze the data and study the results

Step 2: Do Try out the test on a

small scale.

Step 4: Act Refine the change, based on what was

learned from the test

Improvement requires setting aims - time-specific, measurable and defining the specific population of patients that will be affected.

Quantitative measures determine if a specific change actually leads to an improvement.

All improvement requires change, but not all change results in improvement. Identify the changes most likely to result in improvement

Method used in the Method used in the model for improvement model for improvement

Utilises a series of small Utilises a series of small rapid cycles rapid cycles

Tests a change quickly Tests a change quickly Does it work?Does it work? Refine the change as Refine the change as

necessary before necessary before implementing on a implementing on a broader scale broader scale


PlanPlan

Two standardised documents were developed for trial - transfusion record and transfusion request form

Recruit participants


DoDo

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


StudyStudy

Parts not completed Why? User feedback essential –

engage with staff Ownership of document


Chart showing number and % of completed Chart showing number and % of completed data items on blood transfusion request data items on blood transfusion request

formsforms

Form orientation changed to portrait

Patient identifiers included in single block. Date field omitted in error (2-10)

Date field added. Clarify wording on section for completion by sample taker.

100% line

Confusion by requester who also signed area for sample taker. Signature field moved for clarity.


ResultsResults

2 standardised documents2 standardised documents Fit for purposeFit for purpose Clear instructionsClear instructions Logical flowLogical flow Make what is right to do easy to doMake what is right to do easy to do Reliability from being guided Reliability from being guided

through the processthrough the process


ChallengesChallenges

Enthusiasts Willing but not enthusiastic Low priority Resistance to change Reluctance to give up bits

important to them


Lessons learntLessons learnt

Start small – minimum resourcesStart small – minimum resources Select an area where staff are Select an area where staff are

willingwilling Engage big users early on – need Engage big users early on – need

ownershipownership Testing in different conditions is Testing in different conditions is

essentialessential Good leadership and clinical Good leadership and clinical

engagement is essentialengagement is essential


Lessons learnt (2)Lessons learnt (2)

Opportunity to challenge Opportunity to challenge obsolete custom and practiceobsolete custom and practice

Keep people engagedKeep people engaged Be prepared for a progress dipBe prepared for a progress dip Benefits of joining with Benefits of joining with 1000 1000

LivesLives Co-opt expert help – use it!Co-opt expert help – use it!


Future developmentsFuture developments

Real-time measurement of Real-time measurement of reduction in transfusion errorsreduction in transfusion errors

Impact of national guidelines, Impact of national guidelines, advice etc.advice etc.

Inclusion of bedside tracking Inclusion of bedside tracking


Finished article?Finished article?


AcknowledgementsAcknowledgements

Joy WhitlockJoy Whitlock 1000 Lives 1000 Lives Improvement Adviser, Cardiff and ValeImprovement Adviser, Cardiff and Vale

Lisa HowellLisa Howell Clinical Governance Support and Development UnitClinical Governance Support and Development Unit