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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.
Pimpun Kitpoka,M.D.
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Pimpun Kitpoka,M.D.
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•
•
•
•
•
Pimpun Kitpoka,M.D.
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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
เวลาทีก่าํหนดเวลาทีก่าํหนดเวลาทีก่าํหนดเวลาทีก่าํหนดรายงานผลไดทันตามรายงานผลไดทันตามรายงานผลไดทันตามรายงานผลไดทันตามเปอรเซน็ตของการเปอรเซน็ตของการเปอรเซน็ตของการเปอรเซน็ตของการ
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
ผลการตรวจทีเ่รงดวนไดทนัตามเวลาผลการตรวจทีเ่รงดวนไดทนัตามเวลาผลการตรวจทีเ่รงดวนไดทนัตามเวลาผลการตรวจทีเ่รงดวนไดทนัตามเวลา
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
