Audit of Pre-Transfusion Sampling Process in Healthcare
Safer Pre Transfusion
Sampling
Situation
October 2018 a letter to the Medical Director
from CMO requiring assurance about pre transfusion
processes within the health board.
Background
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A Junior doctor attended a patient in EU to take pre transfusion
samples for Group and Save
A request form had not been completed in advance and therefore it
was not possible to positively identify the patient against the details
on the form
The doctor took two samples during the same clinical encounter and
as they were aware that the laboratory would require samples taken
from separate phlebotomy episodes labelled one 17.15 and the
second 17.25
The first sample was tested and grouped as B Rh positive .
The declaration on the second form had not been signed and as a
result was rejected by the lab.
A third sample was requested and was taken by a different clinician.
The third sample was tested and grouped as A Rh positive
Subsequent investigation demonstrated that the initial two tests
had been taken from the wrong patient
Background
Background
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Assessment
Audit of Duplicate Samples
64.8%
patients had the first and confirmatory
sample taken by the same individual
93.6%
of confirmatory samples were recorded as
being taken within 30 minutes of the initial samples
Assessment
16%
of patients who had required a confirmatory sample
(15/94) had blood issued following confirmatory group &
save sampling
1 patient triggered a massive haemorrhage protocol
None of the remaining 14 were transfused with 4 hours
Assessment
Survey of Junior Doctors
7 questions, 3 mins to complete, 35 responses in 1 week
Are you aware of the reasoning behind requiring a confirmatory
Group & Save sample for new patients?
How would you determine whether a confirmatory sample is
required?
Do you feel there is a pressure from either seniors or other
colleagues in not following the confirmatory sample policy?
Do you feel the confirmatory sample policy is sometimes ignored?
Do you feel with better education/information, full compliance of
the confirmatory sample policy could be achieved and sustained?
Further comments/suggestion
Assessment
Survey of Junior Doctors
83 %
were
aware of why a confirmatory sample was
required
60%
said there was pressure from colleagues to not
follow the confirmatory sample procedure
91%
said that the Confirmatory Sample Procedure is
sometimes ignored
80%
said that better education / information would
not
achieve full compliance with the procedure
.
Assessment
Assessment
Executive Safety Notice to All staff -
Some
improvements already demonstrated
Currently exploring the option of making blood group
more visible on the system
Currently exploring the option of developing a patch
that will identify all duplicate samples received in the
lab within a defined period of time
Recommendations
1 Eliminate Second Sample
2 Maintain status quo and reinforce with education
3 Reject second samples undertaken within 30 minutes
and continue to re educate
4 Reject second sample if taken within 2 hours and
continue to re educate
5 Reject second sample within 8 hours if blood not
requested. If blood is requested then the Lab would
contact the requesting clinician and request a further
sample.
An audit was conducted on the pre-transfusion sampling process within a healthcare board, revealing issues such as unnecessary duplicate samples, misidentification of patients, and delays in obtaining confirmatory samples. The audit highlighted the importance of secure electronic patient identification systems and proper procedures to ensure accurate blood transfusions and patient safety.
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Presentation Transcript
Safer Pre Transfusion Sampling
October 2018 a letter to the Medical Director from CMO requiring assurance about pre transfusion processes within the health board. Situation
Unless secure electronic patient identification systems is in Unless secure electronic patient identification systems is in place a second sample should be requested for confirmation of the ABO group of place a second sample should be requested for confirmation of the ABO group of a first time patient prior to transfusion, where this does not impeded the a first time patient prior to transfusion, where this does not impeded the delivery of urgent red cells or other components delivery of urgent red cells or other components Background
A Junior doctor attended a patient in EU to take pre transfusion samples for Group and Save A request form had not been completed in advance and therefore it was not possible to positively identify the patient against the details on the form The doctor took two samples during the same clinical encounter and as they were aware that the laboratory would require samples taken from separate phlebotomy episodes labelled one 17.15 and the second 17.25 Background The first sample was tested and grouped as B Rh positive . The declaration on the second form had not been signed and as a result was rejected by the lab. A third sample was requested and was taken by a different clinician. The third sample was tested and grouped as A Rh positive Subsequent investigation demonstrated that the initial two tests had been taken from the wrong patient
Audit of Duplicate Samples All duplicate samples sent to the lab between 14-21 October were audited 202 patients had 2 or more pre transfusion samples taken Assessment 5 patients had 3 or more samples taken 1 patient had 5 samples taken 53% of duplicate samples were taken unnecessarily
Audit of Duplicate Samples Assessment 64.8% patients had the first and confirmatory sample taken by the same individual 93.6% of confirmatory samples were recorded as being taken within 30 minutes of the initial samples
16% of patients who had required a confirmatory sample (15/94) had blood issued following confirmatory group & save sampling Assessment 1 patient triggered a massive haemorrhage protocol None of the remaining 14 were transfused with 4 hours
Survey of Junior Doctors 7 questions, 3 mins to complete, 35 responses in 1 week Are you aware of the reasoning behind requiring a confirmatory Group & Save sample for new patients? Assessment How would you determine whether a confirmatory sample is required? Do you feel there is a pressure from either seniors or other colleagues in not following the confirmatory sample policy? Do you feel the confirmatory sample policy is sometimes ignored? Do you feel with better education/information, full compliance of the confirmatory sample policy could be achieved and sustained? Further comments/suggestion
Survey of Junior Doctors 83 % wereaware of why a confirmatory sample was required 60% said there was pressure from colleagues to not follow the confirmatory sample procedure Assessment 91% said that the Confirmatory Sample Procedure is sometimes ignored 80% said that better education / information would not achieve full compliance with the procedure.
Executive Safety Notice to All staff - Some improvements already demonstrated Currently exploring the option of making blood group more visible on the system Assessment Currently exploring the option of developing a patch that will identify all duplicate samples received in the lab within a defined period of time
1 Eliminate Second Sample 2 Maintain status quo and reinforce with education 3 Reject second samples undertaken within 30 minutes and continue to re educate 4 Reject second sample if taken within 2 hours and continue to re educate Recommendations 5 Reject second sample within 8 hours if blood not requested. If blood is requested then the Lab would contact the requesting clinician and request a further sample.
