Pimpun Kitpoka,M.D. -...

Pimpun Kitpoka,M.D.

Pimpun Kitpoka

Director of Blood Bank

Clinical AreaPitfalls in Blood Transfusion ChainQuality Management System

Pimpun Kitpoka,M.D.

Director of Blood Bank

Ramathibodi Hospital, Mahidol UniversityDepartment of Pathology, Faculty of Medicine,

donationBlood

componentsof

Preparation

transportissulingTesting ordering

Medical decision

Transfusion

The Blood transfusion chain

Pimpun Kitpoka,M.D.

monitoring

time.righttheatplacerightthein

patientrightthetobloodrighttheGetting

Quality

Quality is an on going activity.Quality starts with me.

Quality is everybody’s responsibility.

Pimpun Kitpoka,M.D.

ProcessesInput Output

Documentation

Standard

Management

Pimpun Kitpoka,M.D.

Training Assessment

ContinuousimprovementAct

Plan

Do

Pimpun Kitpoka,M.D.

improvement

Check

I Hospital Transfusion Practice

ISO / HAsystemEstablish a quality•

• Allow continuous monitoring

Pimpun Kitpoka,M.D.

processtransfusionwholetheof

II Hospital Transfusion Practice

Dispensing Hospital blood bank

Manufacturing Blood Center

Administrating Patients’ locations

Pimpun Kitpoka,M.D.

Administrating Patients’ locations

Labeling sample Blood deliveryDrawing sample Blood product

Patient’s admission Blood donation

III Hospital Transfusion Practice

Pimpun Kitpoka,M.D.

Transfusion reactionBlood deliveryCompatibility testBlood storage

SERVICETRANSFUSION

Patient information / Prescription notes

Established guideline for appropriate use of blood

Procedures for requesting and transfusing blood•

•

•

• Patient / blood sample / blood product Identification

the Quality SystemI Monitoring and Evaluating of

Pimpun Kitpoka,M.D.

• Patient / blood sample / blood product Identification

Monitoring the transfused patients•

elective-

and transfusing bloodProcedure for requesting

- emergency

Pimpun Kitpoka,M.D.

- emergency

- uncrossmatch blood- ABO compatible

ABO identical -

productbloodofvolumeandType

indicatedClearly•

•

• Date of request / operation

Prescription notes

Pimpun Kitpoka,M.D.

• Date of request / operation

productSpecial•

Identification

Analytical phase Wrong tube

Preanalytical phase Wrong blood in tube

Pimpun Kitpoka,M.D.

/ productPostanalytical phase Wrong patient

crossmatchingorandgroupingbloodforused

samplespatients’ofacceptanceforCriteria

policyWritten•

•

/

• Required informations on tube and request form

Acceptance of patients’ samplesI Preanalytical Identification

Pimpun Kitpoka,M.D.

• Required informations on tube and request form

Hospital numberGenderDate

Correctly spelt name

Sample InformationII Preanalytical Identification

Pimpun Kitpoka,M.D.

Correctly spelt name

(OPD, Ward, OR)Location of patient Identity of phlebotomist

Wrong blood in tubeMissing or incorrect informationDesignate it as unsuitable and hold it•

•• - Transfused patient’s

Sample RejectionIII Preanalytical Identification

Pimpun Kitpoka,M.D.

- Transfused patient’s

regardless of the recipient groupgroup O donor blood

- First - time transfusion

in the patients’ historical recordroutinely check ABO blood group

identificationmaintaininginMistakes

Wrong sample•

•

• Mislabeling

Identification during analytical phase

Pimpun Kitpoka,M.D.

• Mislabeling

issuebloodWrong•

Identification before transfusing blood

checkwayThree

procedurecheckingsideBed•

•

patient / blood / record

Pimpun Kitpoka,M.D.

patient / blood / record

sionbar-coded identification to the label of pretransfu

Use of bedside systems that apply to the patient’s

sample.ndpatient’s ABO has been confirmed on a 2

Use of only group O red cells for transfusion until•

•

MistransfusionProcess Control

Pimpun Kitpoka,M.D.

sample is the one receiving the transfusion.system to ensure that the person who gave that

testing sample or by using a mechanical barrier

I Monitoring the transfused patient

Record

reactiontransfusionforWatch

•

•

• Investigation

Pimpun Kitpoka,M.D.

• Investigation

Pimpun Kitpoka,M.D.

Blood bank, Ramathibodi HospitalTransfusion Reaction Work Up Form

Pimpun Kitpoka,M.D.

Pimpun Kitpoka,M.D.

Pimpun Kitpoka,M.D.

II Monitoring the transfused patient

Record

reactiontransfusionforWatch

•

•

• Investigation

Pimpun Kitpoka,M.D.

• Investigation

• Report

Pimpun Kitpoka,M.D.

Blood bank, Ramathibodi HospitalTransfusion Reaction Report Form

Pimpun Kitpoka,M.D.

Transfusion Reaction Form

Pitfalls in Blood Transfusion Chain

Pimpun Kitpoka,M.D.

Errors

Considered the weakest links in the chain.

transfusion chain.Errors can happen at any point along the •

•

Pimpun Kitpoka,M.D.

characterized in a consistent fashion.Error should be analysed , grouped and •

Errors

Sample errors

Decision to transfuse•

•

• Laboratory errors

Pimpun Kitpoka,M.D.

• Laboratory errors

Blood issue and administration errors•

supported by a laboratory result.upon relevant clinical signs and symptoms A decision to transfuse should be based •

Decision to TransfuseErrors

Pimpun Kitpoka,M.D.

Education of the hospital physician.•

Wrong patient

Wrong labeling of sample / blood•

•

Sample errorsErrors

Pimpun Kitpoka,M.D.

errors took place outside of “c ore hours” and A disproportionately high number or laboratory

Wrong blood.•

•

at night, when staff are fewer in number.

Laboratory ErrorsErrors

Pimpun Kitpoka,M.D.

at night, when staff are fewer in number.

urgent and emergency.Transfusion at night should be restricted to •

Transport or transit errors can occur during the

The common pitfall of similar patient names.

Inaccurate verbal instruction.•

•

•

Blood Issue and Administration ErrorsErrors

Pimpun Kitpoka,M.D.

including not storing at adequate temperatures.from wards of operation theatres or vice versa, transfer of the blood and blood components

of the Quality SystemII Monitoring and Evaluation

“ Gap Analysis”a

transfusion-related procedures and performance of r Review of current nursing, operating room, and othe

Pimpun Kitpoka,M.D.

Special Components Blood Component

Patient Testing/Donor Testing/Quality ControlLaboratory

Patient(Donor)

Blood Donation

StructureBlood Establishment

Customer

Pimpun Kitpoka,M.D.

Hospital (Physician / Patient)

Special ComponentsTherapic Intervention

Blood Componentproduction

Customer

Pimpun Kitpoka,M.D.

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Pediatrics units

of the Quality SystemIII Monitoring and Evaluation

internal and external audits and the corrective / Customer complaints received / findings of Review of problems currently encountered•

•

preventive actions put into places

Pimpun Kitpoka,M.D.

preventive actions put into places

or accident, but that could have done so)Nearmiss (events that did not result in an error •

Incident ReportCustomer Complaints and

WhenWhat Brief descriptionWho Reporting individual involved

Where

Components of Internal Event Reports

Pimpun Kitpoka,M.D.

Where

ImplementationCorrective / Preventive actionFollow up

Why and how Root causes

Pimpun Kitpoka,M.D.

Pimpun Kitpoka,M.D.

Incident Report2006 2007 2008 2009 2010

Wrong blood in tube 2 7 0 2 0Near-misses

Mislabeling of blood component 6 2 1 0 1

11 8 13 14 9Mislabeling of specimens

Labeling

••

•

• Wrong blood 2 1 2 0 3

Pimpun Kitpoka,M.D.

• Wrong blood 2 1 2 0 3

Blood component 0 0 0 0 2

Sample 0 0 0 0 1

Rejection

Expired blood 0 0 1 0 0

Wrong type of blood component 1 1 0 0 0

Wrong blood group 1 0 0 0 0•

•

•

•

•

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collections / transfusion reactionissued, which provides a measure of over/under Review of number/type of blood units collected •

• Quality reports on components produced which

of the quality systemIV Monitoring and evaluation

Pimpun Kitpoka,M.D.

• Quality reports on components produced which

donors / recipientsFrequency / nature of adverse reactions in provides a measure of transfusion outcome

•

Ramathibodi Hospital , Bangkok , ThailandTransfusion Reaction

Percent

Pimpun Kitpoka,M.D.

Year

Ramathibodi Hospital, Bangkok, Thailand

Transfusion Reaction : RBC

Percent

Pimpun Kitpoka,M.D.

Year

Ramathibodi Hospital, Bangkok, ThailandplateletTransfusion Reaction : Pooled buffy coat

Percent

Pimpun Kitpoka,M.D.

Year

Ramathibodi Hospital, Bangkok, ThailandTransfusion Reaction : Single Donor Platelet

Percent

Pimpun Kitpoka,M.D.

Year

of the quality systemV Monitoring and evaluation

Analysis of proficiency test (EQAS)•

Pimpun Kitpoka,M.D.

ในระดบั ในระดบั ในระดบั proficiency test ในระดบั proficiency test proficiency test proficiency test จาํนวนการทดสอบทีเ่ขารวม จาํนวนการทดสอบทีเ่ขารวม จาํนวนการทดสอบทีเ่ขารวม การประกันคณุภาพตรวจวเิคราะห จาํนวนการทดสอบทีเ่ขารวมการประกันคณุภาพตรวจวเิคราะหการประกันคณุภาพตรวจวเิคราะหการประกันคณุภาพตรวจวเิคราะห

KPI GoalProcess improvement

international / nationalinternational / nationalinternational / nationalinternational / national

KPI / Clinical Pathology

%%100%100100100%

international / nationalinternational / nationalinternational / nationalinternational / national

Proficiency TestsPercent

Year

KPI / Clinical Pathology

%%100%100100100ผลการตรวจผลการตรวจผลการตรวจผลการตรวจเปอรเซน็ตความถูกตองของ เปอรเซน็ตความถูกตองของ เปอรเซน็ตความถูกตองของ การประกันคณุภาพตรวจวเิคราะห เปอรเซน็ตความถูกตองของการประกันคณุภาพตรวจวเิคราะหการประกันคณุภาพตรวจวเิคราะหการประกันคณุภาพตรวจวเิคราะห

KPI GoalProcess improvement

%

Percent

Proficiency Tests

Antibody identification2010 EQAS sample for syphilis test

Year

rin in samples2009 Syphilis test : False weakly positive from fib2008 Human error Antibody identification

Hospital transfusion committeeBlood utilization reviewManagement review•

••• Hospital transfusion guideline

of the quality systemVI Monitoring and evaluation

Pimpun Kitpoka,M.D.

• Hospital transfusion guideline

Clinical Transfusion PracticeI Functions of the Transfusion Committee

ratio should be less than 2:1≥≥C:T

Monitoring crossmatch to transfusion ratio

≥≥

Pimpun Kitpoka,M.D.

Crossmatch to Transfusion Ratio C:T ratio

Establishing a guideline for transfusion and

How to decrease C : T ratio

indicate excessive requests for crossmatches : C : T ratio > 2

1

a maximal surgical blood order schedule

Pimpun Kitpoka,M.D.

a maximal surgical blood order schedule

usuage is < 0.5 unit

recommended for surgical procedures which blood

), Use of Type and screen (T/S

(MSBOS) using data about past blood usuage

C:T Ratio 2008Blood Bank, Ramathibodi Hospital

C : T ratio

4:1

3:1

Pimpun Kitpoka,M.D.

1:1

C:T Ratio 2008Blood Bank, Ramathibodi Hospital

C : T ratio

4:1

3:1

Pimpun Kitpoka,M.D.

1:1

Clinical Transfusion PracticeII Functions of the Transfusion Committee

Taking corrective and preventive action

infectious / non infectious transfusion reactions

Ensure investigation for near miss events and •

•

Pimpun Kitpoka,M.D.

for non-conformance

RecallsComplaintsDeviations

Corrective and preventive action

Non-ConformanceQuality Monitoring

Pimpun Kitpoka,M.D.

Corrective and preventive action

circumstances, with the recorded agreement of for transfusion only in exceptional

Non-conforming blood components are released

the prescribing physician and the physician of

Non-Conformance / DeviationsQuality Monitoring

Pimpun Kitpoka,M.D.

the prescribing physician and the physician of the blood establishment.

Non-Conformance / ComplaintsQuality Monitoring

events) are documented, are carefully investigated

serious adverse reactions and serious adverse

Complaints and other information (including

for cause , and are followed by recall and

Pimpun Kitpoka,M.D.

for cause , and are followed by recall and implementation of corrective/preventive actions.

Non-Conformance / RecallsQuality Monitoring

back to donor.ok-including tracing all relevant blood components, lo

Action are taken within predefined periods of time,

ho Investigation is undertaken to identify any donor w

Pimpun Kitpoka,M.D.

ho Investigation is undertaken to identify any donor w

the same donor.from To notify recipients of blood components collected

donor.m that retrieve available blood components originating fro

to contributed to a transfusion reaction, and is done

Performance of Hospital Transfusion ServiceIII Functions of the Transfusion Committee

d Surgical cancellation due to unavailability of bloo

Adequacy of blood

Turn around time for emergency request

Operational effectiveness of services•

•

Pimpun Kitpoka,M.D.

KPI/Clinical Pathology

%%100 %100 100 100

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ชมชมชม ชม 5 55.5..1.11ในเวลา 1ในเวลา ในเวลา ในเวลา Stat StatStatขอเลือดแบบ Statขอเลือดแบบ ขอเลือดแบบ ขอเลือดแบบ นาทีนาทีนาที นาที 15 1515ในเวลา 15ในเวลา ในเวลา Initial ในเวลา Initial Initial ขอเลือดแบบ Initial ขอเลือดแบบ ขอเลือดแบบ ขอเลือดแบบ

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KPI GoalProcess improvement

%

Pimpun Kitpoka,M.D.

Percent

Turn Around Time/Stat Blood Request

Pimpun Kitpoka,M.D.

2007 : The patient had RBC antibodies

Year

Conclusion

Pimpun Kitpoka,M.D.

Humans will inevitably make errors

decreases errors and detect residual errors.The system design must be such that it

Pimpun Kitpoka,M.D.

2000; 40:879 - 885 sfusion Myhre and McRuer. Human error and mortality. Tran

omesErrors in the transfusion process and potential outc

Failure to prescribe special

Unnecessary prescriptions

Problem Outcome

componentsRisk of, for example, transfusion-

Wastage of blood componentsPatient subjected to unnecessary risk

associated graft versus host disease

Pimpun Kitpoka,M.D.

components

controlled environmentFailure to keep blood in

associated graft versus host disease

on MedicineFrom Murphy MF, Pamphilon DH. Practical transfusi

Wastage of blood components

hemolytic transfusion reactionsPotential for acute and delayed

transfusionpotential for an ABO-incompatable

transfusion testingpre-Insensitive techniques in

and patients samples Incorrect identification of

OutcomeProblem

omesErrors in the transfusion process and potential outc

Pimpun Kitpoka,M.D.on MedicineFrom Murphy MF, Pamphilon DH. Practical transfusi

coagulopathyPatient morbidity from hypoxia or

Shortages of some groupInappropriate use of group O Wastage of units

components in an emergencyDelay in provision of blood

Poor laboratory stock control

Conclusion

effective implementation at all levels.

the organization, ensuring proper understanding and

out for the communication of the quality system through

Quality documentation should provide a framework

lity.In general terms, quality is everybody’s responsibi•

•

• Continuous improvement is one of the main goals of

Pimpun Kitpoka,M.D.

• Continuous improvement is one of the main goals of

means of internal and external audits.y accomplished through formal management review and b

is is The quality system should be evaluated regularly.Th

the quality system.

•

Thank you for your

Pimpun Kitpoka,M.D.

for your attention