Safe Blood Transfusion

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Safe Blood Transfusion

• Prepared by Vicki Martens
• Project Manager Transfusion Medicine Improvement
  Program
• Clinical Governance

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Benefits of Transfusion

• Obvious, well known, life saving ??
• Evidence and Data lacking
• Jehovahs Witness better outcomes
• Hard to justify possible HARM if you cant
  justify using blood.

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Expert Opinion

• Debate is On-going
• www.thetransfusionquestion.com.au
• On-Line debate around appropriate transfusion
• Medical Officers can contribute comments and
  review expert opinions
• 7 topics
• Links to research articles

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Why focus on Transfusion?

• Known and emerging Risks
• Must balance with Benefit
• Minimise risks in our control
• Errors in sample collection and labelling remain
  the leading cause of patient related morbidity
  and mortality. (Aust. Patient Safety Bulletin,
  March 2009)

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Risks in Transfusion

• Risks from the products
• Viral infections HIV, Hepatitis, HTLV
• Emerging new agents vCJD, Dengue, West Nile
• Bacterial infection, Immune Modulation, TRALI
• Risk from LACK of products
• donor age, travel exclusions

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Avoidable Risks

• Poor Patient Identification
• Wrong Blood in Tube
• Wrong Product transfused
• Wrong Patient transfused
• Failure at any point ?Sample collection ?Lab
  tests ?collection of product ?bedside transfusion

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Following the Procedure

• Results of recent observational study in HNEH
  site
• Error labelling tube - 14
• Error on request form - 9
• Tube labelled away from patient - 89
• Patient correctly Identified - 17

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Wrong Blood in Tube?

• No Way not me!
• Frequency 1 in 400
• Usually undetected
• Possibly fatal due to
• ABO Incompatibility

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Appropriate, Safe Blood

• Appropriate need, appropriate dose
• Guidelines, evidence, data
• Documentation of indication, consent
• Safe processes, following procedures

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Transfusion Administration Form

• Indication / reason for transfusion
• Informed consent
• Provides information for patient / parent /
  guardian to read available in 10 languages
• Multiple episodes consented 12 months
• Prescription of the blood

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HNEMR - 17
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Credentialing Staff

• All staff involved in transfusion process
• NSW Dept Health, NBA, HNE Health PCP
• BloodSafe e-Learning program
• Interactive, informative, modular, quizzes
• Certificate on completion, CNE Points

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Demonstrated Improvement

• Audit results
• 2008
  2009
• Documented Consent 20
  100
• Documented Reason 40
  85
• IIMS reports 7 per day
  2 per day (collection errors)

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Intranet Website
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In the end.

• By Introducing
• The Form
• Credentialing
• The Website
• Achieve Improvement in
• Consent
• Appropriateness
• Sample error rates
• Safer Transfusion for PATIENTS