The risk that a red blood cell unit will be associated with an ABO-incompatible transfusion is currently slightly greater than the aggregate risk of acquiring human immunodeficiency virus, human T-cell lymphotropic virus, hepatitis B virus, or hepatitis C virus by transfusion. Since the most common cause for ABO-incompatible transfusion is the failure of transfusionists to properly identify a patient or a blood component before a transfusion, transfusion services are encouraged to evaluate and monitor the processes of dispensing and administering blood. In addition, a proposal of the Health Care Financing Administration of the Department of Health and Human Services would require hospitals to use a data-driven quality assessment and performance improvement program that evaluates the dispensing and administering of blood and that ensures that each blood product and each intended recipient is positively identified before transfusion. The Los Angeles County+University of Southern California Medical Center assesses the blood dispensing and administering process as proposed by the Health Care Financing Administration. During the fourth quarter of 1997, 85 blood transfusions were assessed for compliance with the Los Angeles County+University of Southern California Medical Center policies and procedures: 55 transfusion episodes had no variance from institutional protocol and 30 had one or more variances. Of the transfusions with at least one variance, 16 had one or more variances involving the identification of the patient, the component, or the paperwork. The remaining 14 transfusions had one or more variances involving other criteria (nonidentification items). The most frequent variance was the failure to document vital signs during the first 15 minutes after a transfusion was started or after 50 mL of a component had been transfused. No variances in patient or blood component identification were noted in nursing units whose staff routinely performed self-assessment of blood administering practices. Based on these findings, a corrective action plan was implemented. Follow-up assessments (n = 63) were conducted after 3 months (during the second quarter of 1998). The compliance with the pretransfusion identification protocol improved from 81% to 95%. The most common reason for noncompliance continued to be a lack of checking vital signs. This report demonstrates the value of using a data-driven program that assesses blood administering practices.
Current methods of donor education, screening, and testing have led to a remarkabledecrease in the incidence of transfusion-transmitted infection. Recent data indicate that the per unit risk of transmitting hepatitis B virus, hepatitis C virus, human T-cell lymphotropic virus, or human immunodeficiency virus by transfusion of a red blood cell (RBC) unit is less than 1:60 000, 1:100 000, 1:500 000, and 1:500 000, respectively.1 The aggregate risk of transmission of these viruses is about 1 per 34 000 units, with hepatitis C virus and hepatitis B virus accounting for 88% of the residual risk of viral transmission. In contrast, data from New York indicate that the per unit risk of an RBC unit being ABO incompatible with its recipient is about 1:33 000.2 Thus, today, the risk is slightly greater that an RBC unit will be associated with an ABO-incompatible transfusion than transmit human immunodeficiency virus, human T-cell lymphotropic virus, hepatitis B virus, or hepatitis C virus. Since the most common cause of ABO-incompatible transfusion is the failure of transfusionists to properly identify a patient or a blood component before a transfusion (ie, errors in the pretransfusion identification process3), transfusion services are now being encouraged to voluntarily evaluate and monitor the processes of dispensing and administering blood.4 In addition, if approved, a December 1997 proposal of the Health Care Financing Administration of the Department of Health and Human Services would require, as a condition of participation with Medicare, hospitals to use data-driven quality assessment and performance improvement programs that evaluate the dispensing and administering of blood and that ensure that each blood product and each intended recipient is positively identified before transfusion.5
A blood administering assessment program has been in effect at the Los Angeles County+University of Southern California (LAC+USC) Medical Center since 1991, and this program is described in detail elsewhere.6,7 However, in 1995, the Los Angeles County Department of Health Services experienced a devastating financial crisis that threatened to close several county health care facilities, including the LAC+USC Medical Center. In response to the crisis, state, federal, and local officials collaborated to develop a plan to stabilize the county health care system and to implement a series of system modifications. The plan called for reconfigured services so that there would be a wider distribution of outpatient and primary care services and a reduction in the number of inpatient beds by almost 40%. Inpatient clinical support services (including nursing and laboratories) were targeted for major staff reductions. Thus, in October 1995, the number of laboratory and nursing personnel was reduced sharply by approximately 25% and 15%, respectively. Not only was the number of staff reduced, but employees with lower seniority who were not laid off were demoted and reassigned. These new assignments were either within the same hospital or in other county hospitals within Los Angeles County. The dramatic changes in the staffing of the clinical support services resulted in a reduction in compliance with blood administering policies and procedures from nearly 100% to only 84%.7 Fortunately, this deterioration in performance did not lead to a catastrophic event.
The data demonstrating the deterioration in transfusion practices were presented directly to hospital administration, nursing administration, and the medical staff via the hospital transfusion committee. However, due to the draconian downsizing of the institution and extremely limited resources, asystematic corrective action plan could not be immediately implemented. In addition, the human resources that had been assigned for the purpose of performing the assessments of blood administering practices were also curtailed as part of the institution's downsizing. Thus, after March 1996, the assessment of blood administering practice could no longer be systematically performed by independent assessors. As a stopgap measure, the Department of Nursing agreed to perform self-assessments of their blood administering practices. The self-assessments used a form that was modified from the one that had been used by the independent assessors. However, the self-assessments were performed by some but not by all nursing units. After a year and a half of discussions with medical and nursing administration, an ABO incompatible transfusion occurred. Although the incompatible transfusion was due to a laboratory typing error, the incident further heightened concerns for transfusion safety, and a part-time employee was again assigned to perform independent assessments of blood administering practices. During the fourth quarter of 1997 a systematic analysis was performed. The results of that systematic analysis are presented in this report, along with the results of a follow-up survey that was performed to measure the effects of a corrective action plan.
The initial phase of this study took place from October 15, 1997, to December 5, 1997. A registered nurse was trained to observe the process of dispensing and administering blood products for compliance with institutional policies; special emphasis was placed on the proper performance of the pretransfusion clerical cross-check. Transfusions of whole blood, RBC, platelets, and fresh frozen plasma were assessed. The assessed transfusions were usually selected at random, although some of the transfusions were intentionally selected to review the performance of specific patient care areas. Each assessment began at the blood bank where the assessor observed the dispensing of a component. The assessment continued as the component was delivered to the site of transfusion. Each assessment took about 30 minutes to an hour to complete. The results were recorded on a standardized form (Figure) and provided to the chair of the transfusion committee for evaluation. The results of the assessments were discussed at Medical Center Quality Assurance Committee meetings, transfusion committee meetings, and nursing departmental meetings.
Eighty-five blood transfusions were audited between October 15, 1997, December 5, 1997. Approximately 70% of audits were conducted during the day shift, 20% during the evening shift, and remaining 10% during the night shift. There was no significant difference in the variance rates between work shifts. Distribution of variances from compliance criteria among different work shifts is shown in Table 1. Of the 85 transfusions assessed, 55 demonstrated no variance, and 30 showed one or more variances. Sixteen assessments revealed at least one or more variances in the identification process of the patient, the component, or the paperwork. The remaining 14 transfusions assessed revealed variances other than in the identification process. The most frequent variance (in 18% of all transfusions) was the failure to document vital signs during the first 15 minutes after a transfusion was started or after 50 mL of a component had been transfused. Interestingly, no variances in patient or blood component identification were noted in nursing units that had been routinely performing self-assessments of blood administering practices. Rather, the transfusionists who demonstrated variances in the process of patient or blood component identification were assigned to nursing units that did not routinely perform self-assessments of the bloodadministering activity.
Based on the results of the fourth quarter 1997 assessments, a corrective action plan was developed. The corrective action plan consisted of discussing with each nurse manager the overall results of the assessments; an aggregate report of how each nurse manager's personnel performed was also provided. Individual nurses (transfusionists) were not named in these reports, since it was believed that the finding of any variance by a transfusionist meant that all the nursing staff assigned to that transfusionist's area needed to be retrained. In addition, the nurse managers shared the assessment results with all their staff so that the staff received direct feedback. The Department of Nursing reinforced with the nurse managers that they were responsible for the performance of the staff they supervised. In-service training was scheduled and focused on the cross-checking steps of blood administration, since this was of greatest concern. A videotaped in-service training module was used that described the proper method for administering blood. Finally, since the nursing unit personnel who did self-assessments of blood administering practices seemed to perform better than those who did not, a schedule was developed so that personnel in all nursing areas would begin to perform self-assessments.
A follow-up audit was conducted after 3 months (during the second quarter of 1998) to measure the effect of these corrective actions. Table 2 shows the results of the follow-up study. Sixty-three assessments were done during the second quarter of 1998. Compliance with the pretransfusion identification protocol improved from 81% to 95%. In fact, in two cases, patients had not been wearing identification bands at the time the blood component and patient clerical cross-check began. The transfusionists did not proceed with either transfusion. Rather, identification bands were placed on the patients' wrists so that the patients were properly identified before the transfusions were started. However, there were 8 cases in which a physician's order for the transfusion was not written in the medical record. The most common reason for noncompliance continued to be a lack of documenting vital signs.
The LAC+USC Medical Center implemented a blood administering assessment program in 1991. This program uncovered a significant number of transfusions that were being administered without proper identification of the paperwork, the blood components, and/or the intended recipients. The discovery of these variances and the corrective actions that followed improved the compliance of transfusionists to the hospital's pretransfusion identification protocol from a dismal 50% during the first half of 1991 to nearly 100% by 1992.6 However, a dramatic institutional downsizing in 1995 was associated with a reduction in transfusionist compliance with the pretransfusion identification protocol, and the compliance rate in 1996 was measured at 84%7 and 81% in the present study. Not until a systematic plan of corrective action was implemented did the compliance rate with the pretransfusion identification protocol again approach 100%.
The assessment of blood administering practice has demonstrated some interesting findings, including 3 major causes for variance from procedures: (1) insufficient knowledge due to deficiency in orientation or training; (2) poor performance due to lack of acceptance of procedures, indifference, or carelessness; and (3) system deficits.
Our experience shows that the prevention of knowledge deficits and performance deficiencies requires ongoing in-service training of staff. Furthermore, we have discovered that when a transfusionist shows a lack of acceptance to the identification procedure, this can beaddressed by asking the transfusionist why he or she feels a certain procedural step does not need to be followed. For example, it was discovered that when nurses did not understand why they needed to reverify the identity of a patient whom they had been caring for over an extended period (ie, they felt they “knew” their patient), it was explained that the pretransfusion check is also designed to detect dispensing or blood bank errors.
The assessment program has allowed for the monitoring of transfusionist performance and served as an early warning system for when remedial action needs to occur. Yet, one has to ask if the current system of manually checking and comparing patient and blood component identification before transfusion can ever achieve a sustained 100% compliance with institutional protocols. One must wonder if the current system could be replaced by a newer design. For example, computerized portable data terminals can now be used to positively identify patients, specimens, and blood products at the bedside.8 These systems can scan bar coded identifiers on a patient's wristband, a compatibility label, associated paperwork, and a transfusionist's identification badge. Once the information is scanned, the system can verify electronically that the correct patient has been selected and that the correct blood product is about to be transfused. These systems can also record the start and completion dates and times of transfusion and evidence of transfusion reaction; transfusion event details can be documented on a report and printed at the bedside. All these data can be downloaded and transmitted to the blood bank electronically. The use of this type of technology should reduce the mistakes commonly made by transfusionists and may even result in savings by eliminating the need for a second person to do the clerical check at the bedside. In addition, such a system of identification could be used at the time of phlebotomy for laboratory testing, when administering medications, when taking x-ray films, or when doing billing and numerous other hospital procedures.
In summary, this study shows that essential elements of blood administering practice, namely the pretransfusion identification of patient and component, can be monitored effectively and that such monitoring can lead to improvement in transfusionist practice by identifying the need for remedial training. However, to sustain close to 100% compliance with institutional blood administering practices there needs to be continual monitoring of theses practices and/or a new technology needs to be adopted that will reduce the likelihood that transfusionists will fail to comply with institutional transfusion protocols.
Presented at the College of American Pathologists Conference XXXIII, Transfusion Medicine Performance Improvement, which was cosponsored with the American Association of Blood Banks, San Francisco, Calif, August 20–22, 1998.
Reprints: Ira A. Shulman, MD, LAC+USC Medical Center, 1200 N State St, PO Box 778, Los Angeles, CA 90033.