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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
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
BackgroundBackground
SHOT Annual Reports
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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.
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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)
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
Fundamental PrinciplesFundamental Principles
Documentation Communication
Identification
SafeTransfusion
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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)
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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)
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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?
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
PDSA?PDSA?
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
PlanPlan
Two standardised documents were developed for trial - transfusion record and transfusion request form
Recruit participants
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
StudyStudy
Parts not completed Why? User feedback essential –
engage with staff Ownership of document
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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.
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
ChallengesChallenges
Enthusiasts Willing but not enthusiastic Low priority Resistance to change Reluctance to give up bits
important to them
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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!
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
Finished article?Finished article?
Better Blood Transfusion Team Better Blood Transfusion Team Welsh Blood ServiceWelsh Blood Service
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