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How is a tool developed for the

Aerospace Industrybeing used to prevent a leading cause of

ABO incompatible transfusions?

Jo Main

Transfusion Nurse ConsultantPeter MacCallum Cancer Centre

Justine Mizen, Linda Nolte, David Westerman

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What is the leading cause of ABO

incompatible transfusions?

Human error1

Mislabelled specimens what is therisk?

1 Dzik W. Emily Cooley Lecture 2002:Transfusion Safety in the HospitalTransfusion. 2003;43:11901199

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Peter Mac rejects ALL pre-transfusion

blood sample errors

2007

22%

69%

9%

Form Specimen Haemolysed

2008

20%

71%

9%

Form Specimen Haemolysed

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The Hospital Transfusion Committee

monitors rebleeds due to pre-transfusionblood sample errors

2008

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

%

Target % Rebleeds

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Failure Mode and Effect Analysis

What is it and Why use it ?

A systematic, proactive method forevaluating a process to identify where andhow it might fail and to assess the relative

impact of different failures, in order toidentify the parts of the process that are

most in need of change.2

2 Institute for Healthcare Improvement, 2004

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FMEA Process

Phase 1 Understand and Describe the Process

Phase 2 Conduct Failure Mode and Risk Analysis

Phase 3 Redesign Process and Corrective actions

Phase 4 Implementation and Monitoring

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FMEA Tool

RPN = SEVERITY X OCCURRENCE X DETECTION

EFFECTS

CONSEQUENCE

CAUSES

LIKELIHOOD

CONTROLS

EFFECTIVENESS

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FMEA on the

labelling of a pre-transfusion blood sample

Sample labelled

3F. Biohazard bag sent toPathology SpecimenCollection

3A. RN collates tube andrequest form

3B. Full Pt Identifiers arecorrectly handwritten on

sample

3C. RN signs, dates and

records time of draw onsample

3D. RN signs, dates andrecords time of draw onrequest form

3E. Correct sample andcorrect request form areplaced in biohazard bag

Sub process

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Failure Modes

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Failure Mode Risk Priority Numbers

Failure Mode: Specimen tubes are difficult to write on

Severity 10 X Occurrence 9 X Detection 2 = RPN 180

Failure Mode: Human errors in positive patient identification

Severity 10 X Occurrence 6 X Detection 5 = RPN 300

Failure Mode: Physical environment privacy issues

workflow issues

Severity 10 X Occurrence 9 X Detection 7 = RPN 630

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Failure mode: Specimen tubes are difficult

to write onWhy?

Corrective action

New tube

Different pen

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Outpatient Pathology Department (OPD)Clinical Trials

Research NurseNurse

delayed

Nurse tr yingt o concentrate

Clerk w ith aquery

Constant

interruptions

No privacy forpatients

Cluttered,cramped space

Very sociable!

But.Chaotic

I n 1 hour : 32 blood samples collected12 had 0 interruptions

9 had 1 interrupt ion6 had 2 interrupt ions5 had > 2 interrupt ions

Chair 1 16 venepunctures 23 int errupt ions

Chair 2 11 venepunctures 11 int errupt ionsChair 3 4 CVAD accesses 2 int errupt ionsPneumat ic t ube accessed 4x by non OPD st aff .100% of accesses result ed in int errupt ions t o

OPD st aff .

HI GH RI SK!

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Failure mode: Physical environment

- privacy issues- workflow issues

Corrective actionRedesign

New Procedure

Signage

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Redesigning Care Team - LEAN

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Corrective Action Risk Priority Numbers

Failure Mode: Specimen tubes are difficult to write on

Severity 10 X Occurrence 2 X Detection 2 = RPN 40

Failure Mode: Human errors in positive patient identification

Severity 10 X Occurrence 3 X Detection 5 = RPN 50

Failure Mode: Physical environment privacy issues

workflow issuesSeverity 10 X Occurrence 3 X Detection 3 = RPN 90

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OPD rebleeds due to pre-transfusion blood

sample errors

2009-10

0.00

1.002.003.004.005.006.00

7.008.009.00

10.0011.0012.00

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

%

Target % Rebleeds

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What happened in February 2010?

Change in OPD management structure

Staff attitudes

Staff changes

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What did we do?

Informed Clinical Governance

OPD staff Communication Education

No blame Accountability

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Acknowledgement

Liz Cox

Acting ManagerClinical Risk Management

VMIA

THANKYOU