Objectives. Wrong blood in tube. Transfusion Sampling Errors. National Wrong Blood In Tube (WBIT) Survey Results and feedback

Transcription

1 Objectives Transfusion Sampling Errors National Wrong Blood In Tube (WBIT) Survey conducted by Mr John Sheehy Presented by: Fiona Mc Dermott, Haemovigilance Officer, St Vincent s Private Hospital nd March Month Survey June-Aug To assess the availability of policies and training on blood transfusion sampling in Irish hospitals. who takes samples for blood transfusion in Irish hospitals frequency of mislabelled and miscollected (i.e. WBIT) samples To propose solutions to minimise problem PAI Conference Participation rate Wrong blood in tube 9 hospitals transfuse red cells In Ireland Response from hospitals Response rate % Occurs when Blood sample taken from wrong patient labelled with intended patient details Blood sample taken from intended patient labelled with another patient s details Indicates the correct phlebotomy/id procedure was not carried out (ie patient details not checked) Picked up by lab only if the patient whose details are on bottle/form has been previously grouped at the hospital If no historical record is available there is a MAJOR risk of a patient receiving blood products that are incompatible (eg incorrect blood group) Introduction: SHOT Experience Examples of Practices leading to WBIT Sample labelled by a second person away from the bedside. Incorrect patient record selected in A&E. Sample labelled with information from the incorrect prescription chart. Sample labelled with information from the incorrect request form. Another patient s addressograph labels were filed in the notes that were used to identify the patient. All of them could have been prevented by ID of the patient at the bedside National Wrong Blood In Tube (WBIT) Survey Results and feedback Section : Policies, procedures and training

2 Does the hospital have a written policy with explicit criteria for acceptance of samples for blood transfusion? % Is training provided in your hospital for staff involved in sampling for blood transfusion? Yes No 9% Yes No All Some None Is training provided in your hospital for staff involved in sampling for blood transfusion? Who delivers training on sampling for blood transfusion in your hospital? Comments Submitted by 9 respondents (all respondents had option) Challenges in delivering training to doctors including locum doctors ( comments) Other comments referred to staff not receiving training specifically in the act of venepuncture Generally where midwives / nursing / phlebotomy involved training is provided Haemovigilance Officer Medical Scientist respondents non-respondents Nursing/Midwifery Staff Medical Staff Who delivers training on sampling for blood transfusion in your hospital? Comments Submitted by respondents Who is permitted to take transfusion samples in your hospitals? (both routine and emergency) respondents 9 comments referred to the involvement of phlebotomy staff in training in venepuncture comments referred to the use of SNBTS e- learning programme Phlebotomist Medical Scientific Staff Nursing /Midwifery Staff Medical student Intern/House Officer / Registrar Consultant General Practitioner Other Routine Emergency

3 National Wrong Blood In Tube (WBIT) Survey Results and feedback Section : Specimen rejection rates What number of samples are received in the hospital blood bank per annum ()? respondents non-respondents < - -,, -, >, Small to medium sized hospital Medium to large sized hospital Does your hospital have a written policy on sampling for blood transfusion?, Why were samples rejected?, 9 rejected specimens, % Yes YES 9 No Unlabeled Illegible / Unreadable Incomplete or Mismatched Addressograph missing information label used to information on between sample label tube sample tube tube and and / or request form request form Sample tube and / or request form not clearly signed. Other Total specimens received and rejected June August Jun Jul Aug Total for -month period received,,,, rejected 9, 9,9 Average rejection rate per month.9%.%.%.% (or in specimens) Range in rejection rate for the hospitals who responded is.% to.% How do we compare with international figures for mislabelled specimens? Murphy et al, Transfus Med, UK study Rejection rate of.% identified great variation in policies and practice for sample collection.. practice allowing additions or changes to sample tubes & request forms varied regular tracking of the rates of specimen rejection could be used to identify poor performance in individual hospitals Dzik et al, Vox Sang,, -country worldwide study Rejection Rate of.% to.% great variation worldwide in the reported frequency of mislabelled samples, probably representing from variation in policies for sample acceptance..

4 WBIT incidences How were they detected? National Wrong Blood In Tube (WBIT) Survey Results and feedback Section : Wrong Blood In Tube (WBIT) incidents 9 9 Different historical blood group Information received from sampler Investigation 'triggered' in blood bank Detected due to mislabelling of sample WBIT incidences Where did they occur? WBIT incidences Who took the specimens? 9 A WBIT can occur throughout the hospital but there appears to be a higher incidence in the Emergency Dept. Medical NCHD staff appear to be the staff grade involved in most WBIT incidents most respondents stated that nursing / midwifery receive specific training, this staff % grade accounted for % of the WBITs reported No phlebotomy staff involved in WBIT Emergency Dept Theatre ITU Day Ward Out Patients Dept Neonatal Unit 'Routine' Ward Phlebotomist Medical Scientist % Nurse / Midwife NCHD Consultant 'Other' Total specimens received & WBIT incidences June August How do we compare with international figures for WBIT specimens? Jun Jul Aug Total for -month period received,,,, No. of WBIT Incidences Average incidence of WBIT per month.%.%.%.% (or in, specimens) Dzik et al, Vox Sang,, -country worldwide study WBIT Rate of.% to.9% greater variation worldwide in reported frequency of mislabelled samples incidence of WBIT occurred at a more constant rate.. Ansari & Szallasi, Vox Sang,, US study WBIT Rate of.% Grimm et al, Arch Pathol Lab Med,, US study WBIT Rate of.%

5 Total specimens received & WBIT incidences June August One hospital accounted for of the WBIT Jun incidences, reported in this survey.% Jul a WBIT rate, of.% (or in specimens).% Aug This hospital, had a mislabelling rate.% of.% Total for -month period received,9 No. of WBIT Incidences Average rate of WBIT per month.% (or in, specimens) Range in WBIT incidences for the hospitals who responded is.% to.% What have we learned from the study? All respondents have policies and procedures Training to the samplers is provided though with difficulty gaining access to medical staff The data for mislabelling of specimens and WBIT incidents is comparable with international findings though with some variations Where to go from here?? Do we need a national blood transfusion request form? Who will design it?, will we be able to agree? Do we need a national policy on sample acceptance, minimum requirements, use of addressograph label on request from etc,? Will the use of electronic RFID help reduce the problem? Does the use of phlebotomy staff help to reduce the error rate? Does a zero-tolerance approach to mislabelling help to reduce the error rate? How can some hospitals achieve a mislabelling rate of <.% while hospitals of a similar size are nearer %? Near Miss WBIT Emergency Dept Doctor identified patient X, checked ID band and confirmed ID with relative Sample labelled remotely Patient Y addressograph label placed on request form following phlebotomy Patient Y blood group A+, Patient X B+ WBIT identified by Blood Bank and repeat sample requested BCSH Recommendation second sample Unless secure electronic patient identification systems are in place, a second sample should be requested for confirmation of the ABO group of a first time patient prior to transfusion, where this does not impede the delivery of urgent red cells or other components The two samples must be taken independently of each other Staff need to understand the reasons for requesting a second sample and the risk of WBIT

6 Acknowledgements Mr John Sheehy, BSc(Hons), MSc, FAMLS Dr. Margarita Gonzalez, IBTS Cork Ms Sinead Hall, Quality Officer, SVUH