Reflection on 10 years of NHO Reporting - Irish Blood Transfusion ...

‘To err is human,but to report is divine *’<strong>Reflection</strong>s on 10 years of error reportingand what can we learnDr Emer Lawlor, National Haemovigilance Office19 th November 2010*Marion Webb, AABB News Nov/Dec 2001 p25

Official Launch NHO Oct 1999Ref: IBTS Photographic Archive

350300Breakdown of NHO incidents accepted 2000- 2009 (n=2127)Introduction ofEU Directive2502001501005002000 2001 2002 2003 2004 2005 2006 2007 2008 2009Total Number SAE/IBCT SAR

Changing Profile of SAE/IBCTReportsPost Implementation of EUDirective 2002/98/EC

Changing profile of SAE/IBCT reports 2000-2009200180160140120IBCT/SAE100806040Wrong ABO/Rh Dgroup/WrongComponent/Blood toWrong PatientUnnecessary Transfusion2002000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Root Cause Analysis :an earliergift from EuropeMember States shall ensure that reportingestablishments evaluate serious adverseevents to identify preventable causeswithin the process,Article 6.3.(a) EU Commission Directive2005/61/EC

The user friendly Root Cause methodto solve Complex, Multifaceted Problems

Root Cause Analysis• Avoids rush to judgement• Avoids ‘Blame and Train’• Drills downSentinel Event Policy April 1996 JointCommission AHOMarion Webb, AABB News Nov/Dec2001 p25

The blood transfusion laboratory andhaemovigilance in SJH beganundertaking Root Cause Analysis (RCA)on all serious adverse events (SAE)reported to the NHO in June 2008.Since June 2009 extended to Near MissEvents.

Number of RCA’sundertaken in SJHYearSAE’s andSerious NonconformancesNumberreportedto NHONumber ofRCA’sundertaken20083311720092414182010 (toend ofSeptember)26526

• There were 59 events with high risk of potential harm• 13 of these events involved the sample being taken fromthe wrong patient• 13 involved the sample being taken from the correctpatient but being labelled with another patients details• 26 Wrong Blood in Tube (WBIT) events in totalresponsible for 44% of high risk events• All involved doctors

Wrong Blood in Tube SJH 2005 - 201098765432102005 2006 2007 2008 2009 2010Number of wrongblood in tubesamples

Breakdown of Sample errors 2008-2010 SJH5432Incorrect identifiersWrong blood in tube102008 2009 2010

% Total Corrective/Preventative Action Taken/Suggested5%27%50%18%Audit Training Policy/Procedure amendment New Initiative

Examples of some of the newinitiatives relating to sampling.• In response to the increase in sample errorsthere has been an extension of the phlebotomyservices to cover weekends.• Evaluation of extension of pre-admission clinicswhere blood transfusion samples can be taken• There is a recommendation for extension ofBloodTrack® Tx sampling in certain areas of thehospital.

Preassessment Clinics

Preassessment Clinics• Identify correctable causes of anemia• Identification of patients with special transfusionrequirements - previous antibodies• Samples can be taken for Group and antibodyscreen and can be used for crossmatch ifnecessary if special patient ID protocol followed• Necessary response to increase in ‘day ofadmission’ surgery

‘Improvements canonly take place ifeveryone working inthe health service isprepared to work inan open and honestway thatacknowledges ourfailures in order tolearn from them’Minister for Health & Children MaryHarney launching Patient SafetyFirst initiativeSept 2010

Improvements due tohaemovigilance• Better patient identification in hospitals• Improved bedside checking for blood transfusion• Data to support electronic sample taking andadminstration systems• Data to support HIQA recommendation onpatient Unique ID• Appropriate management of warfarin reversal• Reduction in TACO with FFP/SD plasma• Reduction in TRALI• Reduction of AA/FNHTR with platelets in PAS

NHO The future• Should not be the primary collector ofmandatory reactions and events. Role of NHOshould be help in investigation, advice,expertise if needed.• Primary collector should be IMB with dualreporting to NHO. Both should be online (UKmodel)• The NHO needs a Steering Group representingclinical and laboratory stakeholders

NHO should focus on patient safety• Champion introduction National Antibody Register• Help produce guidelines for appropriate use of blood– including CMV negative , irradiated product• Collect delays?NPSA 11 deaths in UK between 2006-2010, 83patients harmed• Collecting Mandatory Near Misses since Jan 2010Collect clinical near misses?All or subset? Wrong Blood in Tube ?• These will require IT resources and may havestaffing implications

Thanks to NHO Team Members1999 - November 2010Past HVOs• Donna Harkin• Phil Keane-Egan• Derval Lundy• Ann O’Connor• Siobhan O’Connor• Mairead SheahanTemporary Director (2005)• Stefan LaspinaPast Administrative Staff• Paula Bolger• Marie Carolan• Angie Corr• Elaine Corrigan• Maria Flanagan• Gillian Horgan• Marion O’RawPresent• Roisin Brady• Marina Cronin• Kathleen Heery• Emer Lawlor• Cathy Scuffil• Jackie Sweeney• Marcia Kirwan (seconded to DCU)SJH HVOs since 1997PresentDeirdre GoughLorraine EganMary ShinePastJoanne McCormickPhil Keane-EganMairead BreenCarmel WhelehanKerry StollThanks also to all staff in IBTS and HHB St James’s Hospital;