Prepared by John Grant-Casey Project Manager October 2009
The National Comparative Audit Programme Background information A series of audits designed to look at the use and administration of blood and blood components Open to all NHS Trusts and Independent hospitals in the UK Collaborative programme between NHS Blood and Transplant & Royal College of Physicians Endorsed by the Care Quality Commission
Why was this audit necessary? The SHOT Haemovigilance Scheme shows that, in the Incorrect Blood Component Transfused category (IBCT), errors can often be traced to the wrong blood being collected from the issue fridge An audit of the process of collecting blood from the issue fridge contributes to our knowledge about this error-prone part of the transfusion process as well as allowing us to demonstrate whether electronic tracking systems, introduced in part to reduce fridge collection errors, are effective.
What were the aims of this audit? The audit aimed to ascertain if, at the time a unit of red cells is collected from a hospital s main blood fridge, the person collecting the unit has adequate written patient details and completes the procedure for collection.
Participation We invited 175 NHS Trusts / hospitals 38 Independent hospitals Who took part 140 (80%) NHS hospitals sent information 28 (74%) Independent hospitals sent information Number of transfused units audited Nationally =5059 North West RTC = 745
Methodology Hospitals were asked to audit 40 collection events (or if less than 40 then all that can be reasonably audited) during the month of June 2009. Auditors were asked to exclude batch transfer of units to other fridges, transfer to other hospitals and emergency issue.
Standards used Standard One A staff member removing blood from the transfusion department issue fridge has documentation containing the patient s identification details by means of a blood collection slip, prescription chart or patient s notes. Standard Two The patient identification details are checked against the details on the compatibility label attached to the unit of blood and, where in use, the compatibility report form or issue slip Standard Three The withdrawal of the unit(s) of blood is documented including name of staff member and time the blood was removed.
Standards used Standard Four Staff members collecting blood for transfusion are trained to undertake this task and this training takes place annually Standard Five Staff members collecting blood for transfusion are assessed as competent to undertake this task and this assessment takes place every 3 years
Please note: The remainder of the slides show results per hospital to allow comparison with regional and national percentages. Hospitals were able to opt out of being named in the slideshow, and data for those who opted not be included is omitted from these slides. Regional percentages are therefore understated.
Number of collections audited Aintree University Hospital 40 Alder Hey Children's Hospital 40 Christie Hospital 32 Countess of Chester Hospital NHS Foundation Trust 30 Cumberland Infirmary 20 East Lancashire Hospital NHS Trust 41 Glan Clwyd Hospital 40 Lancashire Teaching Hospitals NHS Foundation Trust 23 Leighton Hospital 40 Liverpool Heart and Chest Hospital NHS Trust 20 Liverpool Womens Hospital 21 Nobles Hospital Isle of Man 16 Royal Bolton Hospital 30 Salford Royal NHS Foundation Trust 20 Southport and Ormskirk Hospital NHS Trust 40 SPIRE Cheshire Hospital Warrington 9 Trafford Healthcare NHS Trust 40 University Hospitals of Morecambe Bay NHS Trust 40 University Hospitals of South Manchester NHS Foundation Trust 6 Warrington & Halton NHS Foundation Trust 40 Wirral University Teaching Hospital NHS Foundation Trust 40 Wrexham Maelor Hospital 40 Wrightington Wigan and Leigh NHS Trust 37 Ysbyty Gwynedd Hospital 40
% Per grades of staff collecting blood Porter Nurse Doctor HCA ODA Other National 34 38 0.3 22 4 2 Regional 31 38 0 22 4 2 Aintree University Hospital 0 35 3 60 0 0 Alder Hey Children's Hospital 0 25 0 75 0 0 Christie Hospital 44 25 0 28 0 3 Countess of Chester Hospital NHS Foundation Trust 0 67 0 33 0 0 Cumberland Infirmary 95 5 0 0 0 0 East Lancashire Hospital NHS Trust 0 56 2 37 2 2 Glan Clwyd Hospital 0 33 0 65 3 0 Lancashire Teaching Hospitals NHS Foundation Trust 0 70 0 30 0 0 Leighton Hospital 3 33 0 65 0 0 Liverpool Heart and Chest Hospital NHS Trust 50 20 0 25 0 0 Liverpool Womens Hospital 0 48 0 52 0 0 Nobles Hospital Isle of Man 0 100 0 0 0 0 Royal Bolton Hospital 3 40 0 57 0 0 Salford Royal NHS Foundation Trust 0 45 0 50 5 0 Southport and Ormskirk Hospital NHS Trust 0 78 0 23 0 0 SPIRE Cheshire Hospital Warrington 0 100 0 0 0 0 Trafford Healthcare NHS Trust 3 48 0 50 0 0 University Hospitals of Morecambe Bay NHS Trust 0 58 0 35 0 8 University Hospitals of South Manchester NHS Foundation Trust 100 0 0 0 0 0 Warrington & Halton NHS Foundation Trust 20 8 0 73 0 0 Wirral University Teaching Hospital NHS Foundation Trust 5 38 0 55 3 0 Wrexham Maelor Hospital 0 100 0 0 0 0 Wrightington Wigan and Leigh NHS Trust 0 54 0 35 3 8 Ysbyty Gwynedd Hospital 5 75 0 18 3 0 HCA = Healthcare Assistant ODA = Operating Department Assistant
Collection systems in use Electronic Fridge Tracking Electronic Fridge Tracking, Paper Paper National 19 12 69 Regional 21 9 71 Aintree University Hospital 0 0 98 Alder Hey Children's Hospital 0 0 100 Christie Hospital 0 0 100 Countess of Chester Hospital NHS Foundation Trust 0 0 100 Cumberland Infirmary 0 0 100 East Lancashire Hospital NHS Trust 0 0 100 Glan Clwyd Hospital 100 0 0 Lancashire Teaching Hospitals NHS Foundation Trust 0 100 0 Leighton Hospital 0 3 98 Liverpool Heart and Chest Hospital NHS Trust 0 0 100 Liverpool Womens Hospital 0 0 100 Nobles Hospital Isle of Man 100 0 0 Royal Bolton Hospital 0 0 100 Salford Royal NHS Foundation Trust 0 0 100 Southport and Ormskirk Hospital NHS Trust 0 0 100 SPIRE Cheshire Hospital Warrington 0 0 100 Trafford Healthcare NHS Trust 98 3 0 University Hospitals of Morecambe Bay NHS Trust 0 0 100 University Hospitals of South Manchester NHS Foundation Trust 100 0 0 Warrington & Halton NHS Foundation Trust 0 100 0 Wirral University Teaching Hospital NHS Foundation Trust 0 0 100 Wrexham Maelor Hospital 0 0 100 Wrightington Wigan and Leigh NHS Trust 0 0 100 Ysbyty Gwynedd Hospital 100 0 0
% of staff having patient ID when collecting blood National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 84 86 88 90 92 94 96 98 100 %
% patient ID used for collection containing first name National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 98.4 98.6 98.8 99 99.2 99.4 99.6 99.8 100 %
% patient ID used for collection containing last name National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 92 93 94 95 96 97 98 99 100 %
% patient ID used for collection containing date of birth National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 88 90 92 94 96 98 100 %
% patient ID used for collection containing patient ID number National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 0 10 20 30 40 50 60 70 80 90 100 %
% of staff checking blood against patient s ID? National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 0 10 20 30 40 50 60 70 80 90 100 %
% with date of withdrawl documented National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 95.5 96 96.5 97 97.5 98 98.5 99 99.5 100 %
% with time of withdrawl documented National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 0 10 20 30 40 50 60 70 80 90 100 %
% With withdrawl signature documented National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 92 93 94 95 96 97 98 99 100 %
% of staff confirming they had transfusion training National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 88 90 92 94 96 98 100 %
% of staff who had transfusion training in the last year National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 0 10 20 30 40 50 60 70 80 90 100 %
% of staff confirming they have been competency assessed National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 0 10 20 30 40 50 60 70 80 90 100 %
% of staff who have been competency assessed within the last 3 years National Regional Aintree University Hospital Alder Hey Children's Hospital Christie Hospital Countess of Chester Hospital NHS Foundation Trust Cumberland Infirmary East Lancashire Hospital NHS Trust Glan Clwyd Hospital Lancashire Teaching Hospitals NHS Foundation Trust Leighton Hospital Liverpool Heart and Chest Hospital NHS Trust Liverpool Womens Hospital Nobles Hospital Isle of Man Royal Bolton Hospital Salford Royal NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust SPIRE Cheshire Hospital Warrington Trafford Healthcare NHS Trust University Hospitals of Morecambe Bay NHS Trust University Hospitals of South Manchester NHS Foundation Trust Warrington & Halton NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrexham Maelor Hospital Wrightington Wigan and Leigh NHS Trust Ysbyty Gwynedd Hospital 0 10 20 30 40 50 60 70 80 90 100 %
Audit Recommendations Systems should be compliant with the 2009 BCSH Blood Administration guidelines and hospitals should consider using the HACCP audit technique to assess if their blood collection systems are sufficiently robust Only staff authorised, trained and assessed as competent should collect blood components and systems should be in place to restrict access to issue fridges if these criteria are not met. The person collecting blood must bring a document containing the patient s core identifiers (forename, surname, date of birth and unique patient number) and must use this document to check the patient identification details on the laboratory produced label attached to the blood bag. Systems should be in place to prevent blood collection if there are any discrepancies between the patient ID on the documentation and blood bag label.
Audit Recommendations When the blood is removed from the issue fridge, the identity of the person removing the blood should be recorded as well as the date and time of the removal. This audit should be repeated locally in order to assess the effectiveness of local training and competency assessment, and this may be especially beneficial soon after training sessions are delivered or if a critical failure of the system has been identified by a clinical incident. Although not specifically addressed by this audit, the recommendations apply equally to collection of blood in emergency situations and collection of blood from remote issue or satellite fridges.
Acknowledgements Project team: Dr. Megan Rowley, Consultant Haematologist, St. Mary s Hospital & NHSBT; Rachel Moss, Transfusion Practitioner, St. Mary s Hospital, London; Tony Davies, Transfusion Liaison Practitioner, NHSBT / SHOT; Joan Jones, Institute of Biomedical Sciences; Shirley Hannam, National Transfusion Laboratory Managers Group; Tanya Hawkins, Transfusion Practitioner, Royal Berkshire Hospital; Joan Russell, National Patient Safety Agency; Katharine Young, Clinical Standards, Royal College of Physicians; Derek Lowe. Medical Statistician, Royal College of Physicians; David Dalton, Project Officer, National Comparative Audit; John Grant- Casey, Project Manager, National Comparative Audit. Hospital staff who collected the audit data