Eliminating Wrong Blood in Tube Events

From the 2023 HVPA National Conference

Brad Goodman BSE, MBA (New York-Presbyterian Hospital), Cindy Spiegel RPh, MS, CPHQ

The number of WBIT events at NYP Weill Cornell has risen over 200%, increasing the chances for patient harm from an incompatible blood transfusion.

Our project goal was to improve the blood testing process to eliminate WBIT events, beginning with our pilot units in the ED and MICU.

The nursing workflow challenges included not having information for the color and number of tubes needed before entering the patient room as well as printing and carrying multiple patient labels as a workaround to printer availability; both of which increased the risk of improper patient verification. We addressed these by developing a visual indicator within EPIC to display the information needed before going into the room and by installing label printers in each room making the correct labels available at the right time. The provider challenge was over-ordering T&S’s. The lab accrediting agency recommends a frequency of every 72 hours for repeat T&S’s; however, we saw repeat T&Ss ordered every 48 hours. No option existed in Epic for every 72 hour T&S’s, so we subsequently created one.

Using standard work developed with the team, the staff’s performance was monitored. The average pre-pilot percentage was 43% for ED and 61% for MICU. Post pilot observations were 100% for both units, demonstrating complete adherence to the standard work. The interventions are currently being spread across nine hospitals in our health system.

Lessons learned included the importance of designing a process that makes it easy for staff to do the right thing, and always test ideas on a small scale to assess impact while minimizing risk.

Clinical Implications:
This project reduced the chance of a WBIT event which could have led to catastrophic outcomes, such as death from ABO-incompatible red cell transfusion. Between one and four patients die each year in the US from ABO-incompatible red cell transfusion.

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