Patient-Safety-Learning

This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Magda talks to us about her role as Family Liaison Officer Team Lead, how PSIRF has changed the way her Trust involves patients and families after patient safety incidents and the importance of placing patient and family perspectives at the heart of learning responses.

In this blog, Laura Green, Consultant Haematologist at NHS Blood and Transplant and Barts Health NHS Trust, describes how a new electronic process to improve the safety of blood transfusions was implemented across all four Barts Health sites. She explains why the new system was needed, outlines the benefits for staff and patients and highlights the role of project governance and staff training in successful implementation. Over the past 18 months, I have been part of a team running Barts Health NHS Trust’s implementation of Vein to Vein—a new bedside electronic process to improve blood transfusion safety. The need for a change to transfusion safety processes Errors in bedside transfusion checks can be very serious, resulting in the wrong blood being given to the wrong patient, which is classed as a ‘Never Event’ in the NHS. At Barts Health, until we implemented the new electronic system, the process of performing safety checks before blood transfusions was a manual one. This included group and screen (G&S) blood sample labelling, which is important for determining a patient’s blood group, as well as blood administration checks. These processes relied on individuals executing each task correctly. As the Trust has a high staff turnover and high blood usage, we had previously introduced additional steps to mitigate risks in the manual process. This safe-proof system involved taking two G&S samples prior to transfusion, the laboratory rejecting any blood samples that were not labelled correctly and requiring two nurses to perform checks at the point of administration for all blood units transfused to patients. Despite these mitigation steps and intensive staff training, humans inevitably make errors, especially when under stress. The 2017 Serious Hazards of Transfusion (SHOT) report emphasised the need to introduce Electronic Transfusion Checks to enhance transfusion safety, and we realised that moving to an electronic system across Barts Health would have significant benefits for patient safety. The bedside electronic process consists of portable scanning computers and mobile printers. These devices prompt staff to carry out key steps in the correct order to avoid the wrong blood being given to the wrong patient. The benefits of an electronic transfusion safety process The electronic process has several benefits, all of which facilitate a safer and more efficient service for patients. It ensures that the right blood is given to the right patient. It reduces the rate of blood sample rejection, thus reducing the frequency of re-bleeding patients. This results in less distress for patients, faster delivery of blood transfusion and faster delivery of other treatments like surgery that are dependent on transfusion. It improves traceability of blood components, which is a legal requirement for all hospitals. It removes the need for having two blood samples for compatibility testing for patients who have not been previously tested. It removes the need for two nurses to check blood prior to administration and therefore frees up staff time, allowing nurses to perform other important tasks. Implementing the electronic process It was important to have a pilot stage to ensure the new process worked safely and effectively. For our one-month pilot, we used our haematology day units because they are a controlled environments in which blood is administered more frequently than other clinical areas. We learned some key lessons from the pilot, which we were able to apply in the rollout across the trust. For example, we learned the importance of collecting staff competencies immediately after training to avoid delays in issuing the devices to clinical areas, and of only releasing the devices for use when over 60% of ward staff have been trained. We also amended the training materials to reflect user feedback. We then went on to implement the system across the four hospitals at Barts Health in phases, starting with elective transfusion wards and then moving to theatres and accident and emergency departments. This allowed clinical teams to become familiar with the system before it was used in emergency settings. We ensured that the principles of the implementation were the same across all four hospitals so that staff would be clear on the process whichever site they were working on. Staff training is essential to successful implementation—transfusion training is currently a mandatory requirement nationally for all staff handling blood. During the rollout stage we agreed that the project team would directly train staff until a critical mass of over 60% of staff had been trained. After this we moved to ‘train the trainer’ model and integrated training on the process into our mandatory training for all staff. Inevitably, we came across various challenges when implementing the system. Electronic transfusion checks rely on patients wearing the right wristbands, so we needed to make sure that all our hospitals had a robust system in place to ensure that patients are wearing the correct wristband. It’s also important to prepare staff for times when technology might fail, so we realised that mandatory training for blood transfusion should continue to include manual checks. Project governance, staff engagement and lessons learned One of the reasons we have been able to deliver this change project successfully is that we ensured our project governance aligned with the Trust’s transfusion governance. We had a dedicated project board made up of senior leaders from nursing, ICT, communications, managers and transfusion, who worked very closely with the quality and safety boards at each hospital to champion the project and engage with clinical staff at all levels. My advice to someone running a similar project would be to engage early on with their trust’s ICT department, transfusion laboratory, senior nurses and patient safety team, so that key stakeholders are invested from the beginning. It’s also important to have a dedicated project board to hold the project team and hospital leaders accountable for delivering the change. Most importantly, it’s vital to work closely with clinical teams to understand their needs, in order to ensure that the new configuration works for them!

This webinar for UK healthcare professionals will be delivered by DISN UK Group committee members. It will focus on using diabetes technology–insulin pumps, CGM, POCT–in the hospital. We will discuss and outline the newest JBDS technology guideline and provide the attendees with most up to date information regarding using diabetes technology when a person with diabetes is admitted to hospital. Educational outcomes – 3 points: Recognise different types of diabetes technology Use of diabetes technology in the different scenarios in inpatient setting Effective support for people with diabetes and use of diabetes technology when admitted to hospital Register for the webinar