Transfusion Research

Reducing Patient Harm from Blood Transfusion

Project Coordinator:Shelly Jeffcott
Investigators: Shelly Jeffcott, Cathie Steele, Peter Cameron, Louise Phillips, Erica Wood
Background: There is a need to address the substantial risk that process errors have on patient safety during blood transfusion.  The most common error involving patient identification that occurs in the process of blood transfusion is when samples in which a properly labelled tube identifying blood from Patient A actually contains blood from Patient B.  This is called ‘Wrong Blood in Tube’ – or a ‘WBIT’.   WBITs can start a complex chain of events which compromise patient safety in two ways: (1) WBITs are a precursor to ‘Incorrect Blood Component Transfused’ or ICBT; (2) WBITs lead to inappropriate therapy due to incorrectly matched results. Approaches to prevent their occurrence have been attempted but had limited success.  This project intends to combat the lack of knowledge surrounding the WBIT problem.  Interventions must be designed that address the full range of systems issues behind WBITs if they are to be effective. 
Aims:The key aims of the project are: To carry out a "human factors" analysis of processes and opportunities for increased system resilience in blood sample collection (including observations, interviews and FMEA risk tools). To review the effectiveness of existing strategies in place to combat ‘Wrong Blood In Tube’ (WBITs) across three public hospitals in Victoria. To develop best practice guidelines for reducing potential patient harm from blood sample collection which are applicable to all Victorian hospitals by 2010 (and which could be applied across other patient identification areas, such as pathology, radiology and surgical procedures).
Method: Pending
Results: Pending
Status: Design / Implementation
Staff: Shelly Jeffcott, Alice Noone
Publications: Pending
Student/s: N/A
Contact Person:Shelly Jeffcott - shelly.jeffcott@med.monash.edu.au