1. Better Blood Transfusion Team Welsh Blood Service Addressing Patient Safety in Transfusion: standardising documentation Maria Cheadle Karen Shreeve Better Blood Transfusion Team

2. Welsh Blood Service Purpose  To improve the reliability of the transfusion process  To achieve this through standardisation −Documentation −Process

3. Better Blood Transfusion Team Welsh Blood Service Background  120,748 blood components issued by Welsh Blood Service 2006-2007  Adverse events due to transfusion process errors  Range of transfusion charts and forms throughout Wales  Standardisation −All-Wales drug chart in use −All-Wales anticoagulant chart being developed

4. Better Blood Transfusion Team Welsh Blood Service Background SHOT Annual Reports

5. Better Blood Transfusion Team Welsh Blood Service  Lack of understanding of what a bedside check involves, and why A 67-year old female patient in a side room was prescribed a transfusion. A trained housekeeper took the correct patient documentation to the issue fridge, but collected a unit of blood for a different patient with the same first and last name. The unit was checked outside the side room, against the compatibility statement, by two nurses. The transfusion record was completed by both nurses indicating that all checks had been completed. One nurse then entered the room and administered the blood without a bedside ID check. The patient was group O RhD positive and received a unit of A RhD positive red cells. The already severely ill patient developed respiratory problems and died later that day, though there was no record of haemolysis.

6. Better Blood Transfusion Team Welsh Blood Service Background  Lack of understanding of the reasoning behind the decision making process in transfusion  Underpinning knowledge and familiarity with transfusion protocols absent  Process failures  Worrying disregard for protocol and an offhand attitude to bedside checking  Patients receiving blood without prescription  Patients with no identification receiving components  Prescription based on incorrect results or poor/absent clinical reasoning

7. Better Blood Transfusion Team Welsh Blood Service Background “If qualified, educated and competent staff take full responsibility for ensuring patient safety, the type of cases described…..could be consigned to history.” (SHOT, 2007)

8. Better Blood Transfusion Team Welsh Blood Service Background  SHOT 2007 – general recommendations −junior doctors’ education −qualified, trained and competent staff to be responsible for transfusion safety −laboratory and clinical area  Junior doctors’ dynamic training process −exposure to a wide and varied range of documentation  National Comparative Audits (2003, 2005, 2008) −transfusion episodes often poorly documented

9. Better Blood Transfusion Team Welsh Blood Service Fundamental Principles Documentation Communication Identification Safe Transfusion

10. Better Blood Transfusion Team Welsh Blood Service The problem…  WBS BBT recognised need to standardise documentation as a priority  Aim - Improve the safety and quality of transfusion practice  Opportunity to link to1000 lives campaign  Endorsed by WAG Clinical Advisory Group and Medical Directors of all Welsh Trusts

11. Better Blood Transfusion Team Welsh Blood Service Project goals  To standardize the underpinning processes associated with the transfusion process through the development of an All-Wales blood transfusion request form and transfusion record  To achieve 95% reliability in documentation correctness and completeness associated with the transfusion process (proxy measure for understanding and complying with the process)

12. Better Blood Transfusion Team Welsh Blood Service Project Measures  Process Measures −% completion of documentation (initially stratified into different elements to target improvement)  Balancing Measure −Staff satisfaction with the request form and transfusion record (e.g. time to complete, relevance of component parts of form, perception about added safety)  Outcome Measure −‘days between’ adverse incidents (may be stratified into transient, permanent or fatal)

13. Better Blood Transfusion Team Welsh Blood Service Documents already in use  Is it all necessary?  How will we know?  Who can help us?

14. Better Blood Transfusion Team Welsh Blood Service Our journey…..  Destination - standardised transfusion documentation in use across Wales  Vehicle - 1000 lives campaign and PDSA

15. Better Blood Transfusion Team Welsh Blood Service PDSA?

16. Better Blood Transfusion Team Welsh 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: Study Set 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 model for improvement  Utilises a series of small rapid cycles  Tests a change quickly  Does it work?  Refine the change as necessary before implementing on a broader scale

17. Better Blood Transfusion Team Welsh Blood Service Plan   Two standardised documents were developed for trial - transfusion record and transfusion request form   Recruit participants

18. Better Blood Transfusion Team Welsh Blood Service Do   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

19. Better Blood Transfusion Team Welsh Blood Service

20. Better Blood Transfusion Team Welsh Blood Service Study   Parts not completed   Why?   User feedback essential – engage with staff   Ownership of document

21. Better Blood Transfusion Team Welsh Blood Service Chart showing number and % of completed data items on blood transfusion request forms 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.

22. Better Blood Transfusion Team Welsh Blood Service Results  2 standardised documents  Fit for purpose  Clear instructions  Logical flow  Make what is right to do easy to do  Reliability from being guided through the process

23. Better Blood Transfusion Team Welsh Blood Service Challenges   Enthusiasts   Willing but not enthusiastic   Low priority   Resistance to change   Reluctance to give up bits important to them

24. Better Blood Transfusion Team Welsh Blood Service Lessons learnt  Start small – minimum resources  Select an area where staff are willing  Engage big users early on – need ownership  Testing in different conditions is essential  Good leadership and clinical engagement is essential

25. Better Blood Transfusion Team Welsh Blood Service Lessons learnt (2)  Opportunity to challenge obsolete custom and practice  Keep people engaged  Be prepared for a progress dip  Benefits of joining with 1000 Lives  Co-opt expert help – use it!

26. Better Blood Transfusion Team Welsh Blood Service Future developments  Real-time measurement of reduction in transfusion errors  Impact of national guidelines, advice etc.  Inclusion of bedside tracking

27. Better Blood Transfusion Team Welsh Blood Service Finished article?

28. Better Blood Transfusion Team Welsh Blood Service Acknowledgements Joy Whitlock1000 Lives Improvement Adviser, Cardiff and Vale Lisa HowellClinical Governance Support and Development Unit