Final Fate Traceability Blood Transfusion Ms Lorna Macfarlane 4 th yr BMS student Glasgow Caledonian University

Overview 4 Summer job 4 Background to final fate traceability 4 “bag and tag” labelling system 4 Practice in NHS Lanarkshire 4 Project findings and outcomes

“Summer job” 4 Transfusion Audit Assistant – Worked on training databases – Undertook some simple transfusion audits – Looked closely at traceability 4 Student Annual Quality Award –Final Fate Traceability

Final Fate Traceability 4 EU directive –2005 –Unambiguous final fate on all blood components –Red blood cells, FFP, cryo, and plats (Anti-D) 4 MHRA 4 Data must be recoverable for 30 yrs –Electronic or paper (or both)

Bag and tag labelling 4 National Scottish label – all hospitals, approx 4 years 4 Attached to every blood component 4 “pink” label for casenotes 4 “blue” label for completion in ward and return to lab

Pink label Signed, timed, dated Attach to documentation

Blue label Wishaw Local slide 28(2008) sign and print, date and time clear and legible return to lab within 48 hrs lab staff enter details on tag onto computer system

Practice in NHS Lanarkshire 4 3 sites 4 Bag and tag introduced Feb 2006 –Excellent support from clinical staff –Near 100% compliance (but this takes a great deal of effort) 4 Daily processes vary 4 Extremely time consuming 4 Limited compliance statistics available 4 Identified as project to review and possibly standardise practice

Blue label compliance 4 Pass = blue label returned to lab within 48hrs 4 1 st pass fail –Incomplete –Non return 4 Lab intervention (send duplicate label or return 1 st label) 4 Time extension 4 Datix

Project observations 4 Local practice –2 sites had dedicated staff, 1 did not –1 site had documentation, confusing, rarely completed fully, and no “ownership “ of the task. 2 sites had no documentation, and no method of recording data –All sites struggled to produce regular stats to monitor label non-return

Next steps… 4 Designed a generic non-compliance form –x 3 sites to record non compliance

Next steps… 4 Designed a generic non-compliance form –x 3 sites to record non compliance 4 Designed an easy to follow flow chart

Next steps… 4 Designed a generic non-compliance form –x 3 sites to record non compliance 4 Designed an easy to follow flow chart 4 Developed a method to report monthly stats

Recommendations 4 Keep forms simple 4 Ensure staff complete them 4 Record monthly stats 4 Report non compliance to wards

Conclusion 4 Loved my time in Transfusion 4 Found this project really interesting 4 Great chance to see different working practice in different labs