Risk assessment document for National Patient Safety ...

Risk assessment document for National Patient Safety AgencySafer Practice Notice 14

Recommendations of York Hospital Transfusion CommitteeApril 2007

The following risk assessments reflect the assessment of hazards which represent asignificant risk to the staff and patients receiving a blood or blood productstransfusion within the York Hospital NHS Trust.

The risk assessments have been completed using guidance from the HSE Leaflet‘Five Steps to Risk Assessment’ (INDG163) and in accordance with themanagement of Health and Safety at Work regulations (1999) and in line with theworkplace risk assessment form guidelines for the York Hospital NHS Trust version2 Jan 2006.The risk assessment details the following factors when considering each factorassociated with the transfusion process.

HazardA brief summary of the hazard the risk assessment for blood transfusion refers to.

Who might be harmed?All of the people who could be harmed by the hazard need to be considered–In thisincident it will usually be the receiver of the transfusion, the patient.

Potential problemIf a hazard presents no problem and the control measures in place are sufficient,then the details have still been recorded.

SeverityEach hazard has been assessed against the risk matrix shown below in table 1 forthe severity rating. The severity rating is calculated using the matrix shown in table2.

ProbabilityEach hazard has been assessed against the risk matrix shown below in table 1 forthe probability rating.

Control measuresThe control measures for each hazard have been identified and recorded. Furtherassessment is detailed if existing measures are not adequate to control the risk withaction plan of how to reduce or eliminate the risk as appendices on the document.

http://www.go2pdf.com

Calculate the riskOn the risk matrix in table 1, severity is the horizontal axis, and Probability thevertical axis:-the risks are rated as:

Green = Low, Yellow = Medium, Red = High

Risk registerThe risks will be placed on the Trust/directorate risk register;Red “high” risks should be actioned/escalated as soon as is reasonably practicable.Inform Risk & Legal Services if any red risks fall outside your directorate’sfinancial/organisational capability or if it is a Trust-wide issue that needs to be placedon the Corporate Risk Register.

Record the riskThe risks once completed will be sent to the Quality Manager of the LaboratoryMedicine for his review and also to the Trust Risk and Legal department for theiropinion. A copy will then be kept on Q pulse, the Laboratory Quality Manual.

Assessments will be reviewed on a regular basis by the Hospital TransfusionCommittee

Table 1 Risk Matrix

Probability

Almostcertain - 5 5 10 15 20 25

Likely - 4 4 8 12 16 20

Possible - 3 3 6 9 12 15

Unlikely - 2 2 4 6 8 10

Rare - 1 1 2 3 4 5

Negligible - 1 Minor - 2 Moderate - 3 Serious - 4 Catastrophic – 5

Severity


Table 2 Matrix to work out severity of risk

Severity ofincident

Injury /Illness

PatientExperience

Systems / project /targets/ objectives

Complaints /Claims

FinancialLoss

AdversePublicity

Catastrophic

Death ormajor andpermanentincapacity

or disability

Totallyunsatisfactory

patient outcome.

Failure of criticalsystem/

project/targets/objectives

Multipleclaims or a

single majorclaim

over£1,000,000

Nationwidemulti mediacoverage

Serious

Majorinjuries, orlong termincapacity

or disability

Patient outcomeor experiencesignificantly

below reasonableexpectation

across the board

Partial failure of criticalsystems, projects,objectives or target

achievement.

Aboveexcessclaim,

multiplejustified

complaints

£50,000 -£1,000,000

Extensivelocal

coverageand

widespreadNHS

coverage.

Moderate

Significantinjury or illhealth –medical

interventionnecessary –

sometemporaryincapacity.

Patient outcomeor experience

below reasonableexpectation inone or more

areas.

Resolvable problemwith critical system,

project, target orobjectives

achievement

Partial failure ofimportant system,project, target or

objective achievement.

Failure of peripheralsystem/project/target

or objectiveachievement.

Justifiedcomplaintinvolving

the lack ofappropriate

care, orbelow the

excessclaim.

£5,000 -£50,000

Coveragethroughout

theorganisation

and / orsome public

coverage

Minor

Minor injuryor ill health– first aid or

selftreatment –

noincapacity

Patientexperiencetemporarily

unsatisfactory –rapidly resolved.

Resolvable problemwith important system,

project, target orobjective achievement.

Justifiedcomplaintperipheralto clinicalcare (e.g.

Car parking/ access

£500 -£5,000

Coveragelimited toelementswithin the

organisation(e.g. tradeunions and/or someexternal

stakeholders

Negligible

Injury orillness notrequiring

intervention

Single resolvableproblem in

patientexperience.

Resolvable problemwith peripheral system,

objective or project.

Low valueclaim

handled byan ex gratia

payment

£0 -£500

Awarenesslimited to

individualswithin the

organisation


RISK ASSESSMENTS – BLOOD TRANSFUSION

OverallRiskLevel

Reviewed dates:

1 Correct Patient Request identifiedClinician requests blood x-matching /transfusion

Yellow March2007

2 SamplingRecord / check patient ID

Red March2007

3 SamplingLabels generated using CPD data –request form

Yellow March2007

4 SamplingSample taken labelled andtransported to laboratory

Red March2007

5 LaboratorySample checks by lab staff

Green March2007

6 LaboratoryProduction (selection) of bloodcomponents

Yellow March2007

7 Blood IssueBlood issued from blood bank

Green March2007

8 Blood issueClinician prescribes blood

Red March2007

9 AdministrationCollection of blood from blood fridge

Green March2007

10 AdministrationRecord blood unit arrival

Green March2007

11 AdministrationBedside patient check with bloodcomponents

Red March2007

12 AdministrationAdministration and completion oftransfusion

Red March2007

13 AdministrationRecord made of transfusion given

Green March2007

14 Traceability of Blood components Red March2007

15 Diagnosis and management oftransfusion reactions

Red March2007

16 Use of emergency O Negative blood Red March2007

17 Use of blood warmers Red March2007


RISK ASSESSMENTBLOOD TRANSFUSION

P –Probability of HazardOccurringS- severity if hazardoccurred (minor injury –death)R - risk rating (low to high)Green, yellow, red

Activity Assessed: Correct Patient Request identified -Clinician requests blood x-matching / transfusion

Assessor(s) : Hospital Transfusion Team

Date : March 2007

Significant Hazards Groups at Risk Existing Controls P S R

Failure to request specialrequirements of blood (egirradiation)

Inappropriate request

Insufficient / inaccurate data onrequest

Request not communicated toothers

MainlyHaematologypatients, but caninclude renaltransplant patients,paediatrics,maternity, specialcare baby unitpatients

All patients

All patients

All patients

1. Area to indicate specialrequirement on request form

2. New patients via clinicletter/telephone call fromHaematology/

Renal specialistnurses

3. Fludarabine,Caldrabine,Pentostatin, Clofarabine

prescribing update from pharmacybut has weekly lag.4. Special interest flag set of

Laboratory Data Management(LDM).

1. Maximum Blood OrderSchedule

2. BMS review3. Clinical review and training

1. Transfusion Policy2. Lab SOP and review3. Phlebotomy policy

1. Clinical checks and feedback inplace.

2. Transfusion process requireswritten requests to back upverbal requests.

3

2

1

3

3

2

4

2

9

4

4

6


Mis-matching of haematologydata to patient

Request made on wrongpatient

Lack of appropriate training

Special request not explicate

Patients requiring transfusionhave similar names

Inappropriate patient details inpatient notes

Wrong patient notes.

All patients

All patients

All patientsAll staff groups

Haematologypatients

Patients withsimilar names

All Patients

All Patients

1. Repeat requested for grosslyabnormal haematology

2. Protocol requests pretransfusion Hb to be recordedprior to transfusion

3. 2 samples required forElectronic issuing of blood sowherever possible historicalsample available

As above

1. Transfusion Policy2. BMS staff training records

reviewed annually3. Nurse and Medical training

patchy

See Failure to request specialrequirements of blood

See failure to request specialrequirements of blood

1. Warning stickers available inclinical area but not in Laboratory

1. Transfusion Policy2. Phlebotomy Policy3. Laboratory checks/SOP’s


2

2

3

1

1

1

3

3

3

1

1

1

6

6

9

1

1

1

Action Plan for Further Reduction of Risks (Docs / SWPS/ Policies / PPE)

All staff undertaking venepuncture will need to have 3 yearly competency assessmentsundertaken as per National Patient Safety Agency safer practice notice 14 Nov 2006.Annual update on Transfusion awareness available for all staff

Electronic ordering of blood components in line with electronic bar coding/tracking.

Review Date: April 2008


RISK ASSESSMENT

BLOOD TRANSFUSION

P –Probability of Hazard OccurringS- severity if hazard occurred (minorinjury -deathR - risk rating (low to high)Green, yellow, red

Activity Assessed: Sampling - Record / check patientID


Date : March 2007

Significant Hazards Groups atRisk

Existing Controls P S R

Staff use of incorrect patient identification /information to check

Identification of wrong patient

No wristband / identification worn by patient

Patient details incorrect / insufficient

Patient identification / wristband not checked bystaff

Patient unable to verify identification

Differing hospital / NHS / A+E numbers

Wrong notes

Patient gives false identity

Patient details illegible

All patients

All patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

1. Trust Positive PatientIdentification policy.2. Blood Transfusion Policy3. Quality checks inLaboratoryTraining

As Above

As Above

As Above

As Above

As Above4. Unconscious unknownpatients issued with uniqueemergency number

1. LDM merge routine2. CPD control measures


None

1. Laboratory SOP’s

1

1

2

1

1

1

1

1

1

4

5

5

5

5

4

4

1

1

4

5

10

5

5

4

4

1

1



Alteration of policy and procedures in line with competency based training for transfusion process

Potential reduction in risk score through introduction of electronic bar code / electronic trackingsystem complementing other systems in place for checking of patient identity and blood use.

Review Date: March 2008


RISK ASSESSMENT

BLOOD TRANSFUSION

P –Probability of Hazard OccurringS- severity if hazard occurred (minor injury -deathR - risk rating (low to high)Green, yellow, red

Activity Assessed: Sampling - Labels generatedusing CPD data -request form


Date: March 2007



Flaws in CPD system (allows changes to be made)

Incorrect data entered on to system

No labels available / allowed

Writing not legible on request form

Identification not checked against request form

Incomplete information on form and / or sample

Wrong labels in notes

Patients have similar names

Patient not asked – told name

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

1. Data QualityControl

1. Data QualityControl2. Bedside checks3. Quality checks inLaboratory

1. Data QualityControl2. Bedside checks3. Quality checks inLaboratory

1. Not tested inLaboratory

1. Multiple checksthroughout process,contained inTransfusion policy,phlebotomy policy,Laboratory SOP’s

As Above

As Above

1. Quality checksagainst historicrecords on LDM2. Sample handwritten3. Unique numberingsystem

1. Transfusion Policy2. Phlebotomy Policy

1

1

1

1

1

1

1

1

1

3

3

3

1

1

1

1

1

5

3

3

3

1

1

1

1

1

5


Action Plan for Further Reduction of Risks (Docs / SWPS/ Policies / PPE)Electronic system for labelling of transfusion samples at bedside, only possible in line with completeelectronic positive patient identification.Review Date: March 2008



P –Probability of Hazard OccurringS- severity if hazard occurred (minorinjury -deathR - risk rating (low to high)Green, yellow, red

Activity Assessed: Sampling - Sample taken labelled andtransported to laboratory


Date : March 2008

Significant Hazards Groups at Risk Existing Controls P S R

Pre-labelling of sample

Sample labelled with wrong / insufficient data

Staff identification not recorded on form /sample

Samples taken at same time by same person

Wrong laboratory number on request card andsample (interface issue)

Sample / label becomes loose, broken or lost

Sample labelled away from the bedside – error

Splitting of sample and form

Labelling delegated to someone else

Handwritten label – poor / illegible

Size of label incompatible with sample size

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

1. Transfusion Policy2. Phlebotomy Policy3. Laboratory SOP’s

As Above

As Above

1. Laboratory checks, one ofsamples will not be tested andrepeat sample requested2. Electronic Issue operationalrequirements for Laboratories3. Blood transfusion Policy

1.Automated systems inLaboratory2. Laboratory checks andSOP’s

1. Sample not processed






1

1

1

1

1

1

1

1

1

1

1

4

4

1

4

1

1

4

1

4

1

1

4

4

1

4

1

1

4

1

4

1

1

Action Plan for Further Reduction of Risks (Docs / SWPS/ Policies / PPE)Electronic system for labelling of transfusion samples at bedside, only possible in line with completeelectronic positive patient identification.





Activity Assessed: Laboratory - Samplechecks by lab staff


Date : March 2007


ExistingControls

P S R

Inherent laboratory problems (transposition etc)

Errors in identification – are not cross –checked with CPD

Patient details incorrectly registered

Failure to identify errors in sampling

Failure to find historical records compounds error

Multiple records on lab computer

No historical record available

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

1. LaboratorySOP’s2. Primarysampling

1. Bedsidechecks

1. Bedsidechecks

1. AutomatedSystem requiring2 separatesamples

No controls

1. Daily mergelists2. Historic checkon request

1. Two samplepolicy.

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Action Plan for Further Reduction of Risks (Docs / SWPS/ Policies / PPE)Introduction of annual training scenerios for laboratory staff from July 2007in line with MHRA compliance report April 2007




P –Probability of Hazard OccurringS- severity if hazard occurred (minor injury-deathR - risk rating (low to high)Green, yellow, red

Activity Assessed: Laboratory - Production(selection) of blood componentsAssessor(s) : Hospital Transfusion Team

Date : March 2007

Significant Hazards Groups at Risk ExistingControls

P S R

Selection of wrong blood

Unit of blood labelled incorrectly / with insufficientdata

Staff identification not recorded

Special requirements not met

Technical failure in production of identificationlabels (eg missing last digit)

Label falls off

National Blood Service has mis-grouped unit

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

All Patients

1. Serologicalchecks and LDMchecks2. Bedsidechecks3. Training

As above

1, Automatedpassword system



1. Unit will not betransfused

1. No controlmeasure forElectronic issuedblood but wouldbe detected ifserological crossmatch performed

2

1

1

2

1

1

1

4

1

1

4

1

1

5

8

1

1

8

1

1

5


Blood not available. All Patients 1. Clinicaloverride inemergencies2. Contingencyplans

1 1 1


Potential reduction in risk score through introduction of electronic bar code / electronic trackingsystem complementing other systems in place for checking of patient identity and blood use.




P –Probability of Hazard OccurringS- severity if hazard occurred (minor injury -death.R - risk rating (low to high)Green, yellow, red

Activity Assessed: Blood Issue - Bloodissued from blood bank


Date : March 2007


ExistingControls

P S R

Blood not in fridge

No register of blood in fridge

Staff identification not recorded

Wrong blood, with similar name in fridge

Blood in wrong place in fridge

All patients

All patients

All patients

All patients

All patients

1.Lab SOPs2.ElectronicTracking as far asblood issue fridge

1.Lab SOPs2.ElectronicTracking as far asblood issue fridge

1.BloodTransfusion Policy2.ElectronicTracking as far asblood issue fridge

1. Training2. Lab SOP’s3.Blood

TransfusionPolicy

4. ElectronicTracking as faras blood issuefridge

1. Lab SOPs2. BloodTransfusion Policy3. Training

1

1

1

1

1

1

1

1

2

1

1

1

1

2

1

Action Plan for Further Reduction of Risks (Docs / SWPS/ Policies / PPE)The recent introduction of the electronic tracking as far as the issue blood fridge in theatre receptionhas the potential to improve the hazards involved in removing blood from the blood fridge.Competancy based training packages to be introduced to continue to reduce risk.





Activity Assessed: Blood issue - Clinicianprescribes blood


Date : March 2007


ExistingControls

P S R

1. Clinician prescribes blood for wrong patient

2. Details poorly written / illegible

3. Prescription does not meet requirements of patient

All patients

All patients

All patients

1. BloodTransfusionpolicy

2. Safe identificationof Patients Policy

3. Training

1. Medicines CodeNursing CarePolicy (section 1)

2. Trust Standardsfor Documentation

3. Blood TransfusionPolicy

1

1

2

1

5

4

1

5

8


Monitor incident reports and review risk assessment annually





Activity Assessed: Administration - Collectionof blood from blood fridge


Date : March 2007

Significant Hazards Groups at Risk ExistingControls

P S R

Blood taken to wrong ward

Collection form has incorrect / insufficient details

Wrong unit of blood taken from fridge

Multiple collection made by staff at same time

Unauthorised staff collect blood

All patients

All patients

All patients

All patients

All patients

1. BloodTransfusionpolicy

2. Training

As Above

As Above3. Electronickiosk withincreasedsecurity

As Above

As Above3. Electronickiosk withincreasedsecurity

1

1

1

1

1

1

1

1

1

1

1

1

1

1


Unauthorised access to electronic kiosk/blood fridge

Clinical staff take blood when ‘red box’ appears

Laboratory staff unavailability to correct error codes

Computer links down so kiosk unavailable

All Patients

All Patients

All patients

All patients

1. Bar coded access2. Alarms at kiosk andin Laboratory ifunauthorised useraccesses blood fridgevia kiosk3. Magnetic lockingdevice on blood fridgeonly accessable viaelectronic kiosk ornumeric keypad. Codeheld by Lab staff

1. Blood transfusionpolicy to be updated toinclude kioskinformation2. Training all staffgiven bar codes havereceived training onkiosk

1. ‘Red box’ will bepresent on kioskscreen when bloodscanned.2. Training3. Updated transfusionpolicy

1. Kiosk linked toemergency power2. Revert to paperaudit trail

1

1

1

1

4

5

1

1

4

5

1

1


Continue to complete weekly compliance report for traceability tagsMonitor incident reports and review risk assessment annuallyReview Date: March 2008




Activity Assessed: Administration - Recordblood unit arrivalAssessor(s) : Hospital Transfusion Team

Date : March 2007


ExistingControls

P S R

1. Blood unit not recorded

2. Different blood collections arrive on ward at sametime

3. Failure to complete protocol

4. Blood not expected – patient may not be on ward

5. Unwanted blood

6. Blood taken to wrong place

All patients

All patients

All patients

All patients

All patients

All patients

1. BloodTransfusion policy2. Training3. Traceabilityprocedure

1. BloodTransfusion policy2. Training

1. BloodTransfusion policy2. Training

1.BloodTransfusion policy2. Training



1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1


Training and assessment of competencyUpdate transfusion policy and protocol in line with traceability issuesMonitor incident reports and review risk assessment annually

Potential reduction in risk score through introduction of electronic bar code / electronic trackingsystem complementing other systems in place for checking of patient identity and blood useReview Date: March 2008




Activity Assessed: Administration - Bedsidepatient check with blood components


Date : March 2007



1. No wristband / wrong wristband

2. No verbal identity possible

3. Details on unit not checked against patient identity

4. Details on unit not completed

5. No identity check at all

All patients

Unconscious /confused /children /mentaldisabilitypatients

All patients

All patients

All patients

1. Blood TransfusionPolicy – nowristband notransfusion

2. Safe identification ofpatients policy3. Training

1. Blood TransfusionPolicy – no wristbandno transfusion2. Safe identification ofpatients policy3. Training


1. Blood TransfusionPolicy – no wristbandno transfusion2. Safe identification ofpatients policy3. Training4. Lab SOP


2

1

1

1

1

5

5

5

5

5

10

5

5

5

5


6. Staff identity not recorded on transfusion form

7. Details on wristband not complete

8. Check not performed at bedside

9. Baby has changed names

All patients

All patients

All patients

Babies

1. Blood TransfusionPolicy2. Standards for recordkeeping3. Professional codesof conduct4. Training

1.. Safe identificationof patients policy

1. Blood TransfusionPolicy – no wristbandno transfusion2. Training

1. Unique numericidentifier

1

1

1

1

5

5

5

5

5

5

5

5


Training and assessment of competencyMonitor incident reports and review risk assessment annuallyPotential reduction in risk score through introduction of electronic bar code / electronic trackingsystem complementing other systems in place for checking of patient identity and blood use





Activity Assessed: Administration -Administration and completion of transfusion


Date : March 2007


ExistingControls

P S R

Observations not done

Reaction of blood product

Inadequate staff and / or training of staff to monitorinformation

All patients

All patients

All patients

1. Blood TransfusionPolicy2. Protocol asreminder3. Training

1. Lab SOPs re x-matching of blood2. Blood TransfusionPolicy3. Protocol asreminder4. Training

1. Workload analysisto advise on staffinglevels.2. Training schedule

1

1

2

4

4

4

4

4

8


Training already in place, though no assessment of competence.Training and assessment of competency to be developedAnnual workload analysis to inform staffing levelsMonitor incident reports and review risk assessment annually





Activity Assessed: Administration - Recordmade of transfusion given


Date : March 2007


Existing Controls P S RR

Filed in wrong patient notes

Not filed in notes.

Traceability tags not returned

Patients

Patients

Patients

1. Safe identification ofpatient policy.2. Medical RecordsStrategy / SOPS /3. Training

1. Safe identification ofpatient policy.2. Medical RecordsStrategy / SOPS /3. Training

1.Daily collection byMLA of tags used

2.Follow up on nonreturned tags

3.Weekly compliancereport completed

1

1

1

1

1

1

1

1

1


Continue to complete weekly compliance report for traceability tags


Potential reduction in risk score through introduction of electronic bar code / electronic trackingsystem complementing other systems in place for checking of patient identity and blood use





Activity Assessed: Traceability of bloodcomponentsAssessor(s) : Hospital Transfusion Team

Date : March 2007



Tags attached to blood bags not collected andreconciliation not possible

Tags not signed by clinical staff

Loss of tags

All patients

All patients

All patients

1. Daily collection ofTags from clinical areaby MLA

1. Daily collection byMLA allowsretrospective signing oftransfusion takingplace.

1. Daily collection oftags by MLA allows forrapid detection of noncompliance with returnof tags. Secondaryevidence sought andtransfusion confirmed.

1

3

3

4

3

3

4

9

9


Continue to complete weekly compliance report for traceability tagsMonitor incident reports and review risk assessment annuallyPotential reduction in risk score through introduction of electronic bar code / electronic trackingsystem complementing other systems in place for checking of patient identity and blood use





Activity Assessed: Diagnosis and managementof suspected transfusion reactionsAssessor(s) : Hospital Transfusion Team

Date : March 2007



Not reported

Transfusion aborted outside recognised trigger points

All patients

All patients

1. Blood transfusionpolicy2. Training3. Lab SOP’s4. Adverse incidentreporting system

1. Blood transfusionpolicy2. Training3. Lab SOP’s4. SABRE/MHRAguidance documents

1

1

4

4

4

4







Activity Assessed: Use of emergency Onegative bloodAssessor(s) : Hospital Transfusion Team

Date : March 2007



Not reported as being taken

Unable to trace recipient

Transfusion reaction due to uncross matched blood

All patients

All patients

All patients

1. Blood transfusionpolicy2. Training3. Lab SOP’s4.Adverse incident

reporting system5.Electronic kiosk at

blood fridge

1. Blood transfusionpolicy2. Training3. Lab SOP’s4. Traceabilityprocedure using tagand label

1. Blood transfusionpolicy2. Training3. Lab SOP’s4. Adverse incidentreporting system

1

2

1

4

4

1

4

8

1



Review Date March 2008




Activity Assessed: Use of Blood warmersAssessor(s) : Hospital Transfusion Team

Date : March 2007



No training documents available

Limited knowledge of use in clinical areas other thantheatres and Haematology areas.

Giving set on Fenwal set contains 3 way tap

Allpatients/staff

Allpatients/staff

Allpatients/staff

1.Use limited whereverpossible to selectedareas, theatres andMES who havereceived verbaltraining

1. All warmers kept inacute areas, theatres,A&E, ICU where staffhave received verbaltraining.2. If required in otherareas advised to seekassistance3. Request lab toinform transfusionpractitioner if bloodwarmer required forpatient

1.Advise staff toremove 3 way tap ingeneral ward areasprior to priming of set.

1

2

3

4

4

4

4

8

12


Phase out of Fenwal Blood warmers and sets which are of significant risk.Competency based training packages to be introduced for recently acquired blood warmers.



Summary

It is noted in the areas where the risk score is red the recommendations are;

Ø Changes to the transfusion policy and protocol to incorporate the changesrequired by the NPSA safer practice notice

Ø The introduction of competency based training in certain areas of thetransfusion process as previously recommended by the NPSA safer practicenotice 14.

Ø The introduction of an electronic bar code/ tracking system which wouldincorporate patient identification, electronic labelling for samples, electronicordering of blood components, electronic traceability and electronic checkingof bedside administration. This would have the additional benefit of improvingcompliance with the Blood Safety and Quality Regulations (BSQR 2005) asused by the Medicines and Healthcare Regulatory Authority when inspectionof the transfusion process occurs.

As yet there is no Trust in the UK that has a full electronic system that meets allthe NPSA/BSQR requirements, as identified by the NPSA in 2006. However,work towards acquisition of an appropriate system must be commenced as soonas an NPSA and Connecting for Health specification is available.

The NPSA also asked Trusts to look at the feasibility of using:-

1. Photo ID cards, these are to be trialled in the Renal Unit in the short term,with a view to extending the use to frequently transfused patients in themedical setting. They would not reduce risk of wrong blood beingadministered but would complement the current system as the patient wouldbe more engaged in the checking process. The system is still reliant onhuman actions to ensure card is carried when required or checked by staffmembers.

2. A labelling system of matching blood to patient, The Hospital TransfusionTeam felt this system would complicate the method of blood transfusionsamples taken in the Trust and as such do not recommend the change inpractice.


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