Quality management in the transfusion service: case studies in process improvement

Authors

  • Lawrence T. Goodnough,

    1. From the Department of Pathology and the Department of Medicine, Stanford University School of Medicine; and the Stanford University Medical Center, Stanford, California.
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  • Maurene Viele,

    1. From the Department of Pathology and the Department of Medicine, Stanford University School of Medicine; and the Stanford University Medical Center, Stanford, California.
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  • Magali Fontaine,

    1. From the Department of Pathology and the Department of Medicine, Stanford University School of Medicine; and the Stanford University Medical Center, Stanford, California.
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  • Lee Chua,

    1. From the Department of Pathology and the Department of Medicine, Stanford University School of Medicine; and the Stanford University Medical Center, Stanford, California.
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  • Zenaida Ferrer,

    1. From the Department of Pathology and the Department of Medicine, Stanford University School of Medicine; and the Stanford University Medical Center, Stanford, California.
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  • Christine Jurado,

    1. From the Department of Pathology and the Department of Medicine, Stanford University School of Medicine; and the Stanford University Medical Center, Stanford, California.
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  • Peter Quach,

    1. From the Department of Pathology and the Department of Medicine, Stanford University School of Medicine; and the Stanford University Medical Center, Stanford, California.
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  • Marsha Dunlap,

    1. From the Department of Pathology and the Department of Medicine, Stanford University School of Medicine; and the Stanford University Medical Center, Stanford, California.
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  • Daniel A. Arber

    1. From the Department of Pathology and the Department of Medicine, Stanford University School of Medicine; and the Stanford University Medical Center, Stanford, California.
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Lawrence Tim Goodnough, MD, Stanford University Medical Center, 300 Pasteur Drive, Room H-1402, 5626, Stanford, CA 94305; e-mail: ltgoodnough@stanfordmed.org.

Abstract

BACKGROUND: Laboratory-based quality improvement (QI) initiatives can improve clinical outcomes and patient safety.

STUDY DESIGN AND METHODS: We present three cases of QI that impact processes from the transfusion service (TS) laboratory to the patient's bedside.

RESULTS: Case 1 was event discovery reporting (EDR). We were able to reduce our biologic product deviation reports from 41 (17%) of 238 EDRs to only 19 (7%) of 272 (p < 0.01) EDRs after implementation of a QI workflow process. Case 2 was antibody evaluation before elective surgery. We implemented process improvement strategies: 1) surgical safety checklist with confirmation of type-and-screen completion and antibody evaluation before patients can proceed to surgery; 2) specimen retention policy of 30 days to allow advance testing; and 3) daily review to identify specimens needed on day of surgery. After intervention, only 7 (0.3%) of 2298 patients required antibody evaluation on day of surgery, compared to 65 (0.75%) of 8656 patients (p < 0.01) before intervention. Case 3 was wrong blood in tube (WBIT). We have a two-specimen requirement for blood type verification before transfusion. To determine whether trauma patients should be exempted, we reviewed WBIT errors. Six WBIT errors were from the emergency department (an error rate of 1:400) and nine WBIT specimens were institution-wide. Three patients were transfused after correction of the WBIT error. Based on this analysis, our institution agreed that no clinical units shall be exempted from our policy.

CONCLUSION: Successful QI in the TS improves processes that promote efficiency, effectiveness, and patient safety.

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