Right Patient, Right Blood.

Mrs Patricia WattHaemovigilance Practitioner.

June 2009.

Why Haemovigilance?Why Haemovigilance?

HSS Circular MD6/03 Better Blood Transfusion. Appropriate use of Blood sets out a programme of action to,

Ensure that Better Blood Transfusion is an integral

part of NHS care As part of our clinical governance responsibilities,

make blood transfusion safer. Provide better information to patients and the public. Avoid unnecessary blood in clinical practice.

Role of the Haemovigilance Practitioner

Role of the Haemovigilance Practitioner

Patient safety and quality improvement.

Interface between blood bank and clinical areas.

Assessment and management of risk.

Incident investigation and reporting.

Monitor appropriateness of transfusion and of waste.

Information resource

Education for all those involved in the blood transfusion process.

Safe Blood Transfusion.Safe Blood Transfusion.

SHSCT Hospital Transfusion Team

Southern Health and Social Care Trust Blood Transfusion Committee.

N.I. Blood Transfusion Committee.

N. I. Haemovigilance Committee.

Craigavon Area HospitalCraigavon Area HospitalRBC usage 08/09=5550 units

Daisy Hill HospitalRBC usage 08/09= 1925units.

SHOT 1996-2004. SHOT 1996-2004.

Analysis identified that in the United Kingdom,5 patients died as a direct result of being given an ABO incompatible transfusion.

ABO incompatibility contributed to the death of a further 9 patients.

Caused major morbidity to a further 54 patients.

Strategies Strategies

Agree to and start to implement an action plan to ensure that all staff involved in the blood transfusion process are competency assessed and actions completed by 30th January 2009.

Ensure that the compatibility form and patient notes are not used as part of the final bedside check.

Systematically examine local blood transfusion procedures using formal risk assessment process.

Strategies Strategies

Carry out appraisal of the feasibility of using: Barcodes or other electronic identification

and tracking systems for patients samples and blood components.

Photo-identification for patients who regularly receive blood transfusions.

a labelling system of matching samples and blood for transfusion.

Review Methodology. Review Methodology.

Based on the NPSA Notice 14: 2Right Patient, Right Blood”.

Better Blood transfusion – Appropriate use of Blood.

Self assessment completed by 5th March.

Audit of all blood transfusion episodes for period 9th-16th March.

Discussion and visits on 22nd April.

Blood Transfusion Audit. Blood Transfusion Audit.

All members of staff who are involved in blood transfusion episode have successfully completed relevant competency assessment and names are currently being entered been on a database.

Competency 1- Obtaining a sample for pre-transfusion testing.

Competency 2-Organising a request for a blood component for transfusion.

Competency 3- Collecting a blood component for transfusion.

Competency 4- Pre-transfusion check.

Positive outcomes Positive outcomes

RQIA review – strengths and challenges.

Patient safety.

Motivation of staff.

Support of Senior Management.

Moving forward. Moving forward.

Action plan. Documentation. Communication strategies. Sustainability-self inspection audits,

ongoing education, measuring non-compliances, evidencing good practice.

Advice and EnquiriesAdvice and Enquiries

Please contact;-

Mrs Patricia Watt

Area Haemovigilance Practitioner

028 38613740