The Importance of Transfusion Error Surveillance This is step #1 in error management. Jeannie Callum, BA, MD, FRCPC, CTBS
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1 The Importance of Transfusion Error Surveillance This is step #1 in error management Jeannie Callum, BA, MD, FRCPC, CTBS
2 6051 Clinical Errors 9083 Laboratory Errors Errors over 6 years
3 I don t want to make the wrong mistake Yogi Berra
4 Outline Case Learning from other industries Aviation Anesthesiology Essential ingredients of transfusion error reporting With examples from the Sunnybrook transfusion experience
5 ER acute area Nurse assigned to care for 3 patients BED 15 BED 16 BED 17 Patient on list to go To the operating room For hip fracture
6 ER acute area Nurse assigned to care for 3 patients BED 15 BED 16 BED 17 On arrival Group and Screen sent Diagnosis: Chest pain B POS
7 ER acute area Nurse assigned to care for 3 patients BED 15 BED 16 BED 17 6 hours later Group and Screen sent Diagnosis: Hip fracture Order: 2 units CM
8 ER acute area Nurse assigned to care for 3 patients BED 15 BED 16 BED 17 Technologists: calls down to RN to let her know we need a tan tube to allow us to prepare blood [last sample less than 24 hours and new patient] RN: There are no transfusion orders for Bed 16 Technologist: Requisition states patient is in Bed 15 RN: Oh dear! I drew a G&S from Bed 15 and put Bed 16 name on it!
9 Tan tube Group check So we can be assured that a sample on a new patient was independently drawn and labelled
10 ER acute area Nurse assigned to care for 3 patients BED 15 BED 16 BED 17 Still no sample from this Patient OR delayed But no ABO-incompatible transfusions!
11 Why did we implement the tan tube? Our error tracking system told us we needed to! And multiple other system changes failed
12 One error per day at just one hospital!
13 Short-term: increase detection of these errors Long-term: technology to eradicate these errors
14 Outline Case Learning from other industries Aviation Anesthesiology Essential ingredients of transfusion error reporting With examples from the Sunnybrook transfusion experience
15 Success in the airline industry
16 Aviation safety In 1979, the Federal Aviation Regulations clarified the reporting of errors to clearly provide immunity Actually, failure to report is considered a serious error immunity only if reported within 10 days Individuals who fail to report safety hazards need to bear risk from not reporting This resulted in a 6.75-fold increase in reports
17 Success in the US airline industry 1990 Fatal accident rate per 100,000 departures 2004 Fatal accident rate Systems level error-reduction policies per 100,000 departures
18 Why has the Aviation Safety Reporting System has been so effective? Because the pilot is always the first to the crash site Error reporting is part of self-preservation!
19 Success in anesthesia
20 Success in anesthesia 1954 Mortality rate 1 in 1560 Systems level error-reduction Policies* 2000 Mortality rate 1 in 200,000 * Error tracking systems & developments in technology
21
22 Clear recommendations Keep reporting critical incidents to national reporting system The problems reported could often have been prevented by the correct application of existing safeguards no workarounds Preoperative checking procedures should prevent wrong site errors, detect patient allergies, fasting times, etc.
23 Identifies clear issues When anesthetists hand over to recovery staff, they should give explicit instructions on how and where they can be contacted in the event of a problem iv lines should be kept visible [regular checks for misconnection and extravasation] Plans should be in place to obtain essential equipment for safe anesthesia in the event of equipment failure
24 Success in race car driving?
25 Success in race car driving?
26 Safer on the driver?
27 Outline Case Learning from other industries Aviation Anesthesiology Essential ingredients of transfusion error reporting With examples from the Sunnybrook transfusion experience
28 Essential ingredients Anonymous, non-discoverable, nonpunitive, guarantee of immunity for those that commit and report errors Any reporting system that ignore immunity can not operative effectively, especially if voluntary Meet: The transfusion error surveillance system (TESS)
29 Acknowledgement 2 key people to TESS Ana Lima, Patient Safety Nurse Helen Downie, Error Manager
30 Essential ingredients Culture of safety Focus on the system problems latent errors Organizational infrastructure: hardware, software, policies, procedures, human resources policies (workload per person), and patient factors Superficial look at errors focuses on the people rather than on the systems Not the individual compliance with existing systems blame and shame and blame and train Inherently error prone people are rare Identify only habitual rule-breakers cowboys Improvements in healthcare will come from improving the system, not from individual performance
31 Habitual rule-breakers cowboys Rare in medicine study of 2,000 physicians not one bad apple Rare in transfusion medicine Example: Surgeon who takes a patient to the operating room for a high blood loss surgery without going through pre-admission clinic (no group and screen) A failure to plan on your part does not constitute an emergency on my part National Quality of Care Forum 1992; May
32 Punitive unsafe culture: -Individual (not organizational) responsibility -High workload despite known risk -Tolerance of variability of care -Pride in workarounds -Casual communication High reliability organization: -Leadership committed to safety -Reporting system -Adequate resources -Standardization around best practice -Extensive team training -Structured communication
33 Case 68 year old man presented to Sunnybrook after a trip and fall
34 Case Past history of chronic lymphocytic leukemia Platelet count 54 on arrival (his normal baseline) Patient admitted to neurosurgical intensive care with hematology consult Patient administered 4 pools of platelets over 3 days No bleeding sent home
35 Error identified on return to hospital None of the products were irradiated!
36 We did not blame the physicians or nurses! We blamed the systems in which they work
37
38 Essential ingredients Knowing what to report Anything that does not constitute quality care: Providing care associated with the best outcomes Not providing care that is not associated with the best outcomes Providing it within the optimal period of time Successfully delivering it as intended Doing the right things, only doing the right things, at the right time, and in the right way Clarke JR. The American Surgeon 2006; 72;
39 Translation into transfusion medicine? Only giving blood when alternatives have failed or do not exist Remembering to give intravenous vitamin K to reverse warfarin so you don t need PCCs Giving the plasma right before surgery, not the night before Running the RBC slowly with furosemide for the patient with heart failure Doing the right things, only doing the right things, at the right time, and in the right way
40 Essential ingredients Reporting near-misses (aka. near-hits ) Errors that do not harm the patient These are signal of weaknesses in the system that will eventually lead to harm They provide insight into solutions captures successful recovery They are 300x more common than adverse events Allow you to calculate the recovery rate for each error type Near-misses increase our awareness of the constant potential for disaster
41 Goal Near-miss Reporting Adverse events
42 Number of near-misses for every harm event Clinical adverse event: Near miss ratio
43 What about the blood bank laboratory? 1 in 4,541
44 How are we decreasing harm? 21 harm events over 6 years 100% were adverse reactions from unnecessary transfusions Step 1: prospectively screen all orders for all blood products Step 2: mandatory competency assessment of all physicians
45 Plasma Use Prospective auditing Plasma
46 Mandatory Competency Assessment q2years Coming Fall 2012 Pre-test Module 1: Indication for products Post-test 1 Module 2: Adverse reactions Post-test 2 Who: all resident and staff physicians
47 Essential ingredients Easy to report Remove disincentives concerns about anonymity and liability Multiple methods to report paper, electronic Simple to report clinical team already stressed at the workload level Make improvements to motivate people to keep reporting
48 Helen s drop box
49 E-safety
50 Essential ingredients Feedback error data to clinical and laboratory staff Help encourage reporting Benchmarking between departments Help them to identify where they (and you) need to start first
51 Essential ingredients Adding defense mechanisms Information system alerts you if you of a potential high severity error Failing to meet a requirement (e.g., irradiation) Bedside positive patient identification alarms Bedside labeling devices with a 15 sec time out Locks on quarantined products
52 Lock on quarantined skin
53 53
54 Any Mismatch
55 Essential ingredients Overcome organizational and financial obstacles Success will require that we overhaul organization, staffing, training, and technology If severe financial pressures lead to focus on short-term economic survival patient safety will be left behind In blood transfusion we need to transition from focus on the blood centre to focus on the transfusion process at the hospital
56 Essential ingredients Migrate from reactive to proactive management of errors Patient dies Root cause Systems change Near miss Event data Potential Safety issue Systems change
57 Essential ingredients Solve common irritating problems control the chaos
58 Where & why?
59 These errors cost a lot of money Recollection of samples $24.79 per recollection N=3802 samples rejected $95,250 just for the blood bank samples
60 The cost of lost products
61 The location of lost products
62 If we don t make it happen others will encourage us to do it To trigger giant leaps forward in the safety, quality and affordability of health care by: Supporting informed healthcare decisions by those who use and pay for health care; and, Promoting high-value health care through incentives and rewards
63 Outline Case Learning from other industries Aviation Anesthesiology Essential ingredients of transfusion error reporting With examples from the Sunnybrook transfusion experience
64 Error-reporting should not be our final goal, but only a means of learning from our shortcomings to help improve the future care of our patients Charles H. Andrus Dept. Surgery, San Joaquin General Hospital, California
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