Prepared by Julie Horn

Clinical Nurse Consultant Blood and Blood Product

Dianne Jolley

Quality and Safety Manager

Nepean Hospital

Identifying Risks and Implementing Safety Initiatives

In the Beginning

Two risks were identified

– Wastage of blood and blood products

– Safe administration of blood and blood products as per ANZSBT Guidelines & NSW Health Policy Directive

Evidence

2013 Transfusion Medicine dispensed 8,412 units of RBC’s at a cost of $2,903,317.68

2014 Transfusion Medicine dispensed 5,292 units of RBC’s at a cost of $1,826,480.88

Calculation of RBC at approximately $345.14 per unit

Wastage data

DAPI- Discards as a percentage of issues

Financial Year DAPI 2013 to 2014 3.3% 2014 to 2015 1.7 %

IIM’s- reviewing trends

Total IIMs recorded for 2013 was 39 incidents

Total IIMs recorded for 2014 was 44 incidents

Description of Incidents for 2013

0

1

2

3

4

5Wastage

Authority toIssue Form

BloodSample

Wrongblood/tube

Documentation

Description of Incidents for 2014

0

1

2

3

4

5

6Wastage

Authority toIssue Form

BloodSample

Wrongblood/tube

Documentation

Why the reduction in RBC usage? Why the number of IIMs increasing?

Better review process

Education

System Management

Improved Governance Structure

HCQC (Health Care Quality

Committee) LHD

District Blood Transfusion Committee

Standard 7 Working Group

Blood Transfusion Risk working

Group

Nepean Hospital Quality and Safety

Governance Committee

Nepean Hospital Patient Safety and

Quality Committee

Reflective questions from Standard 7 monitoring tool

How do we check that a broad history of blood products use is documented in the patients clinical record?

What review processes do we use to test that patient clinical records are accurate?

What information on blood and blood products (including the benefits, risks and alternatives) is available for clinicians to give to patients?

Right Blood Right Patient Checklist

Identified there were a number of gaps to meet Standard 7 for patient safety and engagement

Applying the WHO surgical “Time Out” to blood and blood product transfusion

To ensure patient were well informed of the risks verses benefits of the transfusion

Right Patient Right Blood Time-out Checklist

Survey Questions for clinical staff

What is your nursing role?

Does your ward or clinical area have this checklist in stock? Y/N

Do you use the checklist when the patient is ordered a blood transfusion? Y/N

Is the checklist helpful? Y/N

Would you make any changes? Y/N

Staff feedback is positive Lithgow Hospital use it for every transfusion completing the

first section before collecting blood

Patient records audited for the presence and completeness of the Right Blood Right Patient Checklist. • 45% had the form present • 50% were complete

Evaluation of patient care

PET

EQATE Audit

Patient Feedback from the Patient Experience Trackers

eQATE Audits comparing 2013 to 2014

eQATE action plan

Clinical Procedure Safety PD 2014_036 Level 2 Procedures

Where to from here

How do we ensure the patient clinical records have the transfusion process and patient care adequately documented?

Patient Blood Management Modules

References

Australia and New Zealand Society of Blood Transfusion Ltd (ANZSBT). Royal College of Nursing of Australia. 2011, Guidelines for the Administration of Blood Products, 2nd Edition, Australian and New Zealand Society of Blood Transfusion. Sydney, http://www.anzsbt.org.au/publications/documents/ANZSBT_Guidelines_Administration_Blood_Products_2ndEd_Dec_2011_Hyperlinks.pdf

Bloodsafe transfusion checklist http://www.transfusion.com.au/sites/default/files/TP-L3-402%20Nursing%20Admin%20Checklist%205.1.pdf

Google Imageshttps://www.google.com/search?site=&tbm=isch&source=hp&biw=1280&bih=625&q=critical+care+patient+blood+management&oq=critical+care+patient+blood+management&gs_l=img.12...1523.33568.0.35894.44.17.2.25.10.0.199.2875.0j15.15.0....0...1ac.1.64.img..25.19.2710.NTqNPhS9C9k#imgrc=_

South Australia Department of Health, 2012, Flippin’ Blood, Blood Safe Program, South Australia, 2nd edition.http://www.transfusion.com.au/resources/flippin-blood/index.html