1. Blood Matters Halifax, NS 2016/11/18
ERROR MANAGEMENT
CONTEMPLATING THE CLIMB
IS IT WORTH THE EFFORT?
Lisa Merkley, BA, MLT
Director, Laboratory Medicine

2. Contemplating the Climb...

3. It takes a village…. Helen Downie, MLT Dr. Jeannie Callum
Dr. Yulia Lin
Ana Lima, TSN
Supervisor, QAO, Seniors
Technologists, Stakeholders

4. Our climb... 1999 MERS-TM 2005 TESS 2016 TESS Version 3 WHAT HOW WHY
SUCCESS
CHALLENGES
BENEFITS

5. Error Management System
WHAT IS IT
ANONYMOUS /NON PUNITIVE EVENT CAPTURE
WEB BASED/ELECTRONIC WITH REPORT CAPABILITIES
WHAT DOES IT CAPTURE
ANY DEVIATION FROM POLICY/PROCESS/PROCEDURE
ACROSS THE TRANSFUSION SPECTRUM
CLINICAL/TECHNICAL
NEAR MISS/ACTUAL EVENTS
POTENTIAL /ACTUAL SEVERITY
CONSEQUENCE/HARM

6. EVENT CAPTURE (Clinical/Technical)
Product Receipt
Product Order
Sample Collection
Sample receipt/
testing
Product Storage
Product Issue
Product Transfusion

7. Data capture for analysis
DESCRIPTION
CAPTURE
Discovery Date/Time
yyyy/mm/dd & Time range (eg. 8am-12pm)
Discovered by
Job description
Discovery Location
Std. Location/sub location
Event
Free Text of event summary
Discovery
Where in the process
Corrective Action
Immediate/long term action
Product Involvement
Denied/Destroyed
Event Date/Time
Person Involved
Event Location
Coding the event
Discovery/Consequence & Event Codes
Event Type
Near Miss/Actual Event
Potential Severity
High/Medium/Low

8. Categorizing the Error
Transfusion Error Reported
Did the error reach the Pt.?
YES NO
Actual Event
Near Miss
Consequence to Pt.?
System Barrier in place?
YES NO
YES NO
Harm
No Harm
Unplanned
Planned 1 2 3 4

9. Why begin the ascent PATIENT SAFETY/ IMPROVED TRANSFUSION PRACTICE
REGULATIONS/STANDARDS
CAN/CSA-Z –
Blood and blood components

10. Why continue the ascent
Individual Hospital systems
Focus-general
No denominator data
No bench marking
Various reporting capabilities
follow-up communication
Being part of a network
Focus-transfusion specific
Bench marking
Provincial /National /International
SIMS/TESS/AABB/SHOT

11. Data Collection

12. Total Event Capture

13. Reaching the Plateau INFLUENTIAL FACTORS Data Collection
Method-paper, electronic
Simple/Complex
Staff engagement
“Just Culture”
Targeted Audits
Change
Recognized as important from assessing peers
Reaching the Plateau

14. Data Integrity
Maintaining the Plateau
Achieving the decent

15. Event Type-Near Miss/Actual
93% Planned recovery

16. Event Type Actual/Unplanned

17. Potential Severity (High 1 in 10)

18. Is it worth the effort?

19. Unless someone like you cares a whole awful lot, nothing’s
going to get better.
It’s NOT!
Dr. Seuss

20. Idea + Action =CHANGE Collection/ Analysis Focus Brainstorm Ideas
Stakeholder
Consultation
Implement
Process Improvement
Idea + Action =CHANGE

21. Remember PDCA DO
CHECK
ACT
PLAN

22. Clinical Errors-where are they occurring?

23. Inappropriate Product Requests
Pre-Printed Transfusion Order

24. Inappropriate Product Order Rates /1000 product requested
PPO

25. Pre-Printed Order (PPO) Forms
Adult Patient:
RBC/Platelets/Plasma/PCC
Cryoprecipitate/Albumin/IVIG
RhIG/Other
Neonatal ICU:
RBC/Platelets/Plasma/Cryo/
IVIG/HBIG/Exchange
Transfusion/Other
Transfusion Medicine Clinic
Outpatients
Flip Side-Txn Guidelines

26. Products Denied

27. Total High Severity Sample Collection Errors

28. Sample Collection Errors
High Severity Sample Labelling Errors ( ) N %
SC02 – Sample not labelled
514
5.5
SC07 – Label incomplete for key patient identifiers*
354
3.8
SH02 – Paperwork and sample ID do not match
213
2.3
SC01 – Sample labelled with wrong patient ID
189
2.0
SC03 – Wrong patient collected 25
0.3
SC10 – Armband incorrect/not available 7
0.1
Total
1302
13.9
Of the 1385 high severity errors, were specifically related to patient ID / labelling errors

29. Sample Collection Event Intervention
2000
ED Pre-printed labels
Reinforcing bedside labelling
2004/05
PPID
Oncology and Transfusion Med Clinic
2005
Confirmatory Specimen
Group O vs. Group Specific Blood

30. Sample Collection Event Intervention
2008
Group & Screen
ABO/Rh (Group Check)
2011
Implementation of unique Blue Top Tube
Change from Blue Top Tube to the “TAN”

31. ABO/Rh Confirmation ONE GROUP ON FILE TRANSFUSION REQUIRED
PT. IN SAME LOCATION AND <24HRS FROM ADMISSION
TAN TUBE ONLY AVAILABLE FROM BLOOD BANK

32. High Severity Sample Collection/ Labelling Errors

33. ePPID (electronic Positive Pt. ID.)
2004
ePPID Implementation (Txn)
Oncology
2005
Transfusion Medicine Clinic
2012
Pre-Admission Clinic

34. ePPID Transfusion Service and beyond!
2010
ePPID
Business Case Development
2012
Phase 1
RFP (enablers-PT./Staff barcode ID)
Hardware
2013
RFP Awarded

35. ePPID Transfusion Service and beyond!
ePPID status to date
Bar coded Armbands
Corporate handheld device identified
SQ Collection Manager Live
Phlebotomy collect areas
Vascular Access Team
Blood Track Tx
In validation

36. IT IS worth the effort!

37. You’re off to Great Places! Your mountain is waiting, so...
TODAY IS YOUR DAY!
Your mountain is waiting, so...
get on your way
Dr. Seuss