Right Patient Right Blood Monitoring Compliance Reference Number:

This is an official Northern Trust policy and should not be edited in any way Right Patient Right Blood Monitoring Compliance Reference Number: NHSCT/12/579 Target audience: This policy is directed to porters, theatre orderlies, Biomedical Scientists, healthcare assistants, phlebotomists, nurses, midwifes and medical staff who participate in the transfusion process. Sources of advice in relation to this document: Aine McCartney, Haemovigilance Practitioner Maureen Entwistle, Haemovigilance Practitioner Replaces (if appropriate): NHSCT Monitoring Compliance with the requirements of NPSA Safer Practice Notice (14) Right Patient Right Blood (NHSCT/10/245) Type of Document: Trust Wide Approved by: Policy, Standards and Guidelines Committee Date Approved: 25 April 2012 Date Issued by Policy Unit: 29 August 2012 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves

April 2012 Right Patient Right Blood Monitoring Compliance

Right Patient Right Blood Monitoring Compliance 1. Introduction The NPSA Safer Practice Notice (14) Right Patient, Right Blood was issued in November 2006 in England and Wales. The safer practice notice was designed to improve the safety of blood transfusions and to promote strict checking procedures at each stage of the blood transfusion process; it is part of a broader national initiative being taken forward collaboratively through the National Blood Transfusion Committee, the Serious Hazards of Transfusion (SHOT) and the National patient Safety Agency. The Department for Health, Social Services and Public Safety in Northern Ireland endorsed the principles outlined in this notice in June 2007and the Northern Trust established a Project Team chaired by Mrs Hazel Baird, Head of Governance and Patient Safety to ensure Trust wide implementation by 31 st January 2009. Better Blood Transfusion 3 Northern Ireland (BBT3NI) HSS (MD) 17/2011 builds on the requirements of HSS (MD) 6/03 Better Blood Transfusion, and aims to promote safe and appropriate provision and transfusion of blood components and blood products. They take into account the requirements of the Blood Safety and Quality Regulations 2005 - Statutory Instrument 2005/50 and Blood Safety and Quality Amendment 2005 no. 2 (BSQR 2005), HSC (SQSD) 30/2007 which endorsed the NPSA Safer Practice Notice 14: Right Patient, Right Blood 2007 (NPSA SPN 14) and the recommendations in the RQIA Report of Blood Safety Review (2010). Target Audience This policy is directed to porters, theatre orderlies, Biomedical Scientists, healthcare assistants, phlebotomists, nurses, midwifes and medical staff who participate in the transfusion process. Responsibilities Overall responsibility for this policy lies with the Haemovigilance Practitioners. Legislative/Policy Compliance National Patient Safety Agency Safer practice Notice 14 Right Patient, Right Blood NPSA/2006/14 Better Blood Transfusion 3 Northern Ireland (BBT3NI) HSS (MD) 7/2011 1

2. Purpose All members of staff involved in the blood transfusion process must be trained and competency assessed in order to participate in the transfusion process. The competency assessments cover: 1. Obtaining a venous sample for pre-transfusion testing 2. Organising a request for a blood component for transfusion 3. Collecting a component for transfusion 4. Preparing and administering a transfusion of a blood component The Trust Haemovigilance Practitioners (HVP) will monitor compliance with the RPRB competencies on a regular basis. All non-compliances will be reported to the individual, their line manager, and the Trust Governance Department. Policy Statement 3.0 Competency 1- Obtaining a venous sample for pre-transfusion testing The details of all samples rejected by the Trust blood banks are recorded regularly by HVP and information such as name of person taking sample, staff group, ward, date and type of error is noted. When the identity of the individual is determined, the relevant database is interrogated to determine whether they are competency assessed. If the name is not on any database a letter is issued (Appendix 1) requiring that the individual submits a copy of their certificate to the HVP. The letter informs staff not to take samples if they have not been assessed and that it is their responsibility to arrange a practical assessment either with HVP or in the clinical area, before they are deemed competent to practice. They are also informed that taking samples whilst not assessed will result in an incident/near miss reporting form being completed. 2

3.1 Staff not competency assessed in sample taking If a member of staff takes a sample when they have not been assessed and deemed competent, the HVP will initiate an incident/near miss reporting form being completed and forwarded to the Trust Governance Department. Each individual will be informed personally that they must desist from taking samples until trained and competency assessed; in addition the following people will be informed: HCA / Phlebotomist Nursing / Midwifery staff F1 / F2 Medical Staff Other Medical Staff Ward Manager & Lead Nurse Ward Manager & Lead Nurse Foundation year post-graduate tutor, educational supervisor & Clinical Director Clinical Director 3.2 Staff making a Wrong Blood in Tube error As 3.1 3.3 Staff making three minor sample errors Minor sample errors are regularly reviewed by HVP for repeated incidents. When an individual has made three errors in sampling a letter is issued (Appendix 2). The letter states that 3 errors have been noted and any further similar incidences will result in the individual being asked to desist from sampling for Blood Bank until re-trained and reassessed as competent by Haemovigilance; these will be reported to clinical governance, the relevant line manager and included in their training record. Copies of the implicated request forms are available from the Haemovigilance Office. 3.4 Staff making additional errors after receiving letter 1 In the event that an individual has further sample errors subsequent to receiving error letter 1 (Appendix 2); the next stage of error reporting will be initiated. A clinical incident report will be written by HVP and the individual will receive a letter asking them to desist from sampling (Appendix 3) until retrained and reassessed by HVP. Copies of the implicated request forms are available from the Haemovigilance Office and line management are informed as described in point 3.1 3

3.5 Staff making additional errors after being desisted and retrained by Haemovigilance In the event that an individual has further sample errors subsequent to being retrained and deemed competent by HVP; the next stage of error reporting will be initiated. A further clinical incident report will be written by HVP and the individual will receive another letter asking them to desist from sampling (Appendix 3) until retrained and reassessed by the Consultant Haematologist with responsibility for blood transfusion. Copies of the implicated request forms are available from the Haemovigilance Office and line management are informed as described in point 3.1 3.6 Locum / temporary staff When locum / temporary staff have been desisted but retrained and deemed competent no further action will be taken. In the event that it has not been possible to retrain the individuals the locum agency will be informed. 3.7 Staff desisted at the end of a contract When staff have been desisted at the end of a contract period but retrained and deemed competent no further action will be taken. In the event that it has not been possible to retrain the individuals the HVP will inform Haemovigilance staff in the Trust to which the individual is moving if known. 4.0 Competency 2, 3 & 4 The Trust Haemovigilance team will undertake regular audits (at least every 6 months) to monitor compliance with the remaining three competencies. All staff involved in the transfusion process that cannot provide evidence of their competence will be desisted and line management and Trust governance informed as described in 3.1. The audit report summary is distributed to Clinical Directors, Lead Nurses, Ward Managers, Nurse Practitioners, Nurse Assessor trainers and members of the trust transfusion committee. Compliance with SPN 14 RPRB will be included in all clinical audits performed by the Trust Haemovigilance team. Reporting mechanism The Haemovigilance team detail the type of errors and the staff groups involved in the quarterly transfusion feedback reports to all ward areas. Composite quarterly transfusion feedback reports are sent to all Lead Nurses and Clinical Directors. Non-compliance with RPRB is reported to the Trust Transfusion Committee and Trust Governance Department. 4

Equality, Human Rights and DDA The policy is purely clinical / technical in nature and will have no bearing in terms of its likely impact on equality of opportunity or good relations for people within the equality and good relations categories. Alternative formats This document can be made available on request on disc, larger font, Braille, audio-cassette and in other minority languages to meet the needs of those who are not fluent in English. Sources of Advice in relation to this document The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. 5

Appendix 1 Trust Haemovigilance Team haemovigilance@northerntrust.hscni.net Antrim Extension 4965 / 7-555-4965 / 9442 4965 Date Staff Details: Non-Compliance of Right Patient Right Blood: Competency assessment Dear It has been noted from Blood Transfusion Request forms that you have taken a sample for Pre-Transfusion Sampling. From February 1 st 2009, only staff who have been assessed as competent in this task are allowed to take these samples as determined by the DHSSPS adoption of the NPSA Right Patient Right Blood Initiative. Any staff who have taken a pre-transfusion sample and who have not been assessed as competent in this task as reported to Clinical Governance as a clinical risk to patients Unfortunately we cannot locate a record of you having been assessed in taking a sample for Pre-Transfusion Testing. If you have been assessed, please forward a copy of your certificate to Haemovigilance Office, Bretten Hall, Antrim Hospital within the next seven days. If you have not been assessed, please arrange an assessment and send a copy of the Certificate to myself Until the time you are assessed as competent in Pre-Transfusion Testing You must not take any more samples for pre-transfusion testing. If you have any queries please contact Haemovigilance, contact details above Yours sincerely Haemovigilance Practitioner 6

Appendix 2 Trust Haemovigilance Team haemovigilance@northerntrust.hscni.net Antrim Extension 4965 / 7-555-4965 / 9442 4965 Staff Details: Date Blood Bank Sample Error Letter 1 Dear. We note at least 3 recent instances where samples that you took for Pretransfusion sampling were refused by the Blood Bank and repeats requested. We would like to bring to your attention that, as the person responsible for taking the sample in question, you carry a responsibility to ensure that the sample and request form are labelled and signed in accordance with agreed procedures. Non- procedural non-compliances could contribute to adverse consequences for the patient and delays in the provision of blood and blood products. Any further similar incidences will be result in you being asked to desist from sampling for Blood Bank until re-trained and reassessed as competent by Haemovigilance. Further incidences will be reported to clinical governance, your line manager and included in your training record. If you have any queries please contact Haemovigilance, contact details above Yours sincerely Haemovigilance Practitioner 7

Appendix 3 Trust Haemovigilance Team haemovigilance@northerntrust.hscni.net Antrim Extension 4965 / 7-555-4965 / 9442 4965 Staff Details: Date: Blood Bank Sample Error Letter 2 Temporary Desist Notice in Sampling for Pre-Transfusion Testing Dear.. Following our letter of ---/---/---, we note a continued failure on your part, to comply with the agreed protocol whilst taking and labelling samples for blood transfusion purposes. Please desist from taking samples for Pre-Transfusion Testing until retrained and reassessed as competent. Please contact Haemovigilance to arrange one to one training and reassessment. Your repeated non-compliance has been reported to Clinical Governance as a clinical risk to patients. A copy of this letter has been sent to your Clinical Director and Line manager Yours sincerely. Dr Philip Windrum, MD, MRCPath Consultant Haematologist Chair NHSCT Transfusion Committee 8