Addressing Patient Safety in Transfusion: standardising documentation

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

2. Purpose • To improve the reliability of the transfusion process • To achieve this through standardisation • Documentation • Process

3. 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. Background SHOT Annual Reports

5. 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. 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. 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. 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. Fundamental Principles Identification Safe Transfusion Communication

10. 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. 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. 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. Documents already in use • Is it all necessary? • How will we know? • Who can help us?

14. Our journey….. • Destination - standardised transfusion documentation in use across Wales • Vehicle - 1000 lives campaign and PDSA

15. PDSA?

16. Improvement requires setting aims - time-specific, measurable and defining the specific population of patients that will be affected. What are we trying to accomplish? How will we know that a change is an improvement? Quantitative measures determine if a specific change actually leads to an improvement. What changes can we make that will result in improvement? All improvement requires change, but not all change results in improvement. Identify the changes most likely to result in improvement Step 4: Act Refine the change, based on what was learned from the test Step 1: Plan Plan the test or observation, including a plan for collecting data Act Plan Study Do 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. PLAN DO STUDY ACT • 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. Plan • Two standardised documents were developed for trial - transfusion record and transfusion request form • Recruit participants

18. 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

20. Study • Parts not completed • Why? • User feedback essential – engage with staff • Ownership of document

21. Chart showing number and % of completed data items on blood transfusion request forms 100% line Date field added. Clarify wording on section for completion by sample taker. Confusion by requester who also signed area for sample taker. Signature field moved for clarity. Patient identifiers included in single block. Date field omitted in error (2-10) Form orientation changed to portrait

22. 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. Challenges • Enthusiasts • Willing but not enthusiastic • Low priority • Resistance to change • Reluctance to give up bits important to them

24. 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. 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. Future developments • Real-time measurement of reduction in transfusion errors • Impact of national guidelines, advice etc. • Inclusion of bedside tracking

27. Finished article?

28. Acknowledgements Joy Whitlock 1000 Lives Improvement Adviser, Cardiff and Vale Lisa Howell Clinical Governance Support and Development Unit