1. Audit on Wearing Identification Wristband during Blood Transfusion at Thalassemia Center 2007 Dr. Khawla Belhoul,Dr. Maisam L. Bakir, Mrs. Linette Saldanha, SN Stella Paulose, SN Dawn Sharon, SN Evangeline Samala, SN Lily Gerald SN Lily Gerald

2. Background Serious adverse events can occur at every step of the process of blood transfusion, the most dangerous one are the result of miss-transfusion. In U.K., the risk of ABO- incompatible red cells transfusion is reported to be of the order of 1 in 100 000 units; this is many times greater than the risk of HIV or hepatitis C virus transmission by blood. Serious adverse events can occur at every step of the process of blood transfusion, the most dangerous one are the result of miss-transfusion. In U.K., the risk of ABO- incompatible red cells transfusion is reported to be of the order of 1 in 100 000 units; this is many times greater than the risk of HIV or hepatitis C virus transmission by blood.  SHOT (Serious Hazards of Transfusion) scheme in the U.K. repeatedly shown that failure of the bedside check is the single most important error in the transfusion process leading to the wrong blood being given.  The optimum way to overcome miss transfusion is for the patient to wear an identity wristband.

3. Background Thalassemia Center Thalassemia Center -The only specialized center in U.A.E. dealing with management of hemoglobinopathies patients. -The only specialized center in U.A.E. dealing with management of hemoglobinopathies patients. - Blood transfusion dependant patients are admitted to the day care unit to receive blood transfusion regularly every 3-4 weeks. - Blood transfusion dependant patients are admitted to the day care unit to receive blood transfusion regularly every 3-4 weeks. - 26-28 patients are admitted daily to the day care unit. - 26-28 patients are admitted daily to the day care unit. - bed occupancy rate usually exceeds 94%. - bed occupancy rate usually exceeds 94%.

4. Background Nursing Triage Guidelines for day care unit at Thalassemia Center Nursing Triage Guidelines for day care unit at Thalassemia Center Identification wristband which contains patient name, health card number, date of birth, sex and nationality Identification wristband which contains patient name, health card number, date of birth, sex and nationality should be placed by the triage nurse for each patient should be placed by the triage nurse for each patient at admission. at admission. these data to be confirmed from the patient /or significant others verbally. these data to be confirmed from the patient /or significant others verbally.  Guidelines for the Administration of Blood in Thalassemia Center I.D. wristband should be worn all the time I.D. wristband should be worn all the time  Discharge guidelines of Thalassemia Center Assigned staff will remove I.D. wristband on discharge. Assigned staff will remove I.D. wristband on discharge.

5. Why this Audit Subject This topic of audit was chosen by prioritization in staff meeting of Thalassemia Center, it was considered high risk, high volume and problem prone area. This topic of audit was chosen by prioritization in staff meeting of Thalassemia Center, it was considered high risk, high volume and problem prone area. The following questions thought of importance and need to be answered: The following questions thought of importance and need to be answered: 1-Are all patients wearing I.D. wristband with accurate information during blood transfusion and till discharge from Thalassemia Center? 2-What are the reasons for non wearing I.D. wristband?

6. Aims of audit To improve Patient health outcome to ensure right blood goes to right patient To improve Patient health outcome to ensure right blood goes to right patient To improve Delivery of care To improve Delivery of care To improve patient identification process during blood transfusion at Thalassemia Center. To improve patient identification process during blood transfusion at Thalassemia Center. To measure compliance of nursing staff with Blood Administration, triage and discharge guidelines of Thalassemia Center. To measure compliance of nursing staff with Blood Administration, triage and discharge guidelines of Thalassemia Center.

7. Standards Our target for best practice Our target for best practice -All (100%) patients should wear I.D. wristband at admission to day care unit of Thalassemia Center and should be removed only at discharge. -All (100%) patients should wear I.D. wristband at admission to day care unit of Thalassemia Center and should be removed only at discharge. -This I.D. wristband should contain full identity information; patient name, health card number, date of birth, sex and nationality. -This I.D. wristband should contain full identity information; patient name, health card number, date of birth, sex and nationality.

8. Data Collection *Reasons for not wearing wristband during blood transfusion and till discharge: a-Patient refuses to put I.D. wristband because the staffs are very familial with the patient. b- Patient takes off the I.D. wristband and clips it to the bed. c- Patient takes off the I.D. wristband and put on bed side table. d- Patient cuts off the I.D. wristband after being worn. e- Patient removed the I.D. wristband because it is so tight. f- I.D. wristband removed to insert cannula and not put back on the patient. g- I.D. wristband removed to obtain venous access and not put back on the patient. h- Patient removes or refuses to wear I.D. wristband because he is able to identify himself. The daily data collection tool of I.D wristband Audit during blood transfusion at Thalassemia Center Specify reason for not wearing I.D. wrist band at time of discharge.* Is the patient wearing I.D. wristband at time of discharge ? Specify the reason for not wearing I.D. wrist band.* Does the wristband contain the full information(if No, specify the missing information)? Is the wrist band information correct against verbal verification from patient? Is the pt wearing I.D. wristband during blood transfusion ? Age Health Card No. NameSN i- Patient carried I.D. wristband in his hand, bag, pocket, etc. k- Patient removed I.D. wristband because he/she is child. l- Patient uses a laminated Health Card with his/her details instead of I.D. wristband. m- Patient is not given I.D. wristband because of short-staffed. m- Patient is not given I.D. wristband because of short-staffed. n- Patient refuses I.D. wristband because of allergic reaction. o- Patient takes the I.D. wristband off after starting blood transfusion. p- Staff didn’t put I.D. wristband. q- No reason. r- Others (specify).

9. Method This was principally a prospective audit. This was principally a prospective audit. All admitted patients in June 2007 All admitted patients in June 2007 Inspected daily during blood transfusion and at the time of discharge Inspected daily during blood transfusion and at the time of discharge Whether wearing I.D. wristband or not? Whether wearing I.D. wristband or not? Reasons for non wearing were recorded. Reasons for non wearing were recorded. The inspection was carried out by audit lead during blood transfusion The inspection was carried out by audit lead during blood transfusion At discharge it was carried out by afternoon shift in charge. At discharge it was carried out by afternoon shift in charge. Data was entered manually into data collection tool. Data was entered manually into data collection tool. Data was analyzed and collated Data was analyzed and collated

10. Results A-During Blood Transfusion 100% 92.32% 7.67%

11. During blood transfusion Reasons of not wearing I.D. wristband %of patientsNo. of patients 1.216 a- Patient refuses to put I.D. wristband because the staffs are very familial with the patient. 0 0 b- Patient takes off the I.D. wristband and clips it to the bed. 0.63 c- Patient takes off the I.D. wristband and put on bed side table. 0.21 d- Patient cuts off the I.D. wristband after being worn. 0 0 e- Patient removed the I.D. wristband because it is so tight. 0 0 f- I.D. wristband removed to insert cannula and not put back on the patient. 0 0 g- I.D. wristband removed to obtain venous access and not put back on the patient. 0.21 h- Patient removes or refuses to wear I.D. wristband because he is able to identify himself. 0.21 i- Patient carried I.D. wristband in his hand, bag, pocket, etc. 0.42 j-Patient refuses to put the I.D. wristband although importance fully explained. 1.015 k- Patient removed I.D. wristband because he/she is child. 0 0 l- Patient uses a laminated Health Card with his/her details instead of I.D. wristband. 0 0 m- Patient is not given I.D. wristband because of short-staffed. 0.21 n- Patient refuses I.D. wristband because of allergy. 0 0 o- Patient takes the I.D. wristband off after starting blood transfusion. 1.819 p- Staff didn’t put I.D. wristband. 0 0 q- No reason. 1.417* r- Others (specify). 7.67 38 Total * 6(1.21%) patients clipped their I.D. wristband on the I.V. dressing and 1(0.2%)patient the staff fixed the sticker of information on the I.V. dressing.

12. Results

13. B-Audit at Discharge Time: B-Audit at Discharge Time: 3.23%96.76%100% Results

14. At time of discharge Reasons of not wearing I.D.wristband %of patientsNo. of patients 1.216 a-patient refuses to put I.D.wristband because the staffs are very familial with the patient. 00 b-patient takes off the I.D. wristband and clips it to the bed. 0.201 c-Patient takes off the I.D. wristband and put on bed side table. 0.201 d-Patient cuts off the I.D. wristband after being worn. 00 e-Patient removed the I.D. wristband because it is so tight. 00 f-I.D. wristband removed to insert cannula and not put back on the patient. 00 g- I.D. wristband removed to obtain venous access and not put back on the patient. 00 h-Patient removes or refuses to wear I.D. wristband because he is able to identify himself. 00 i-Patient carried I.D. wristband in his hand, bag, pocket, etc. 00 j-Patient refuses to put the I.D.wristbnd although importance fully explained 00 k- Patient removed I.D. wristband because he is child. 00 l-Patient uses a laminated Health Card with his/her details instead of I.D. wristband. 00 m-Patient is not given I.D. wristband because of short-staffed. 00 n- Patient refuses I.D. wristband because of allergy. 00 o- Patient takes the I.D. wristband off after starting blood transfusion. 00 p- Staff didn’t put I.D. wristband. 00 q- No reason. 1.618 r- Others (specify). 3.2316 total * All the patients {8(1.61%) patients} clipped the I.D. wristband on the I.V. dressing.

15. Results

16. Our results is comparative to international figures Discussion/Key findings

17. The audit showed that the commonest 3 reasons of non wearing I.D. wristband were: The audit showed that the commonest 3 reasons of non wearing I.D. wristband were: Discussion/Key findings

18. 1-Staff didn ’ t put I.D. wristband, triage nurses forgetfulness they are all aware of Thalassemia center guidelines. they are all aware of Thalassemia center guidelines. Discussion key findings

19. 2- Refusal of patients to wear wristband as they believe that staffs are very familial with them It is known that pt identification errors occur in this setting. It is known that pt identification errors occur in this setting. Discussion/Key findings

20. 3- Clipping the I.D. wristband on the I.V. dressing was a common significant reason both during blood transfusion and at discharge time. Shall we accept this alternative for chronic patients? Shall we accept this alternative for chronic patients? -Allergy to the wristband? -Allergy to the wristband? Discussion/Key findings

21. Recommendations  Continuous training and education all the staff involved in administration of blood all the staff involved in administration of blood 100% of the patients 100% of the patients should positively identified with a wristband or an acceptable alternative. should positively identified with a wristband or an acceptable alternative.  Clipping on the I.V. dressing not accepted unless the patient is allergic to the band not accepted unless the patient is allergic to the band re-clipping if cannula is removed. re-clipping if cannula is removed.

22.  All staff explain to the patient,placing ID wrist band is a routine process to avoid human error.  Re-audit conducted to evaluate the improvement of patient identification process. Recommendations