PART 05 RECOMMENDATIONS

The NBA, in conjunction with the HAC, makes 10 recommendations in this report in the following areas:

National blood quality and safety initiatives

Promote the recognition and management of transfusion-related adverse events
Implement programs at the national, state and local hospital levels to improve reporting of serious adverse events

Reducing human errors

Clinical staff should comply with national guidelines on sample collection and administration of blood and blood products
Promote the application of technological adjuncts such as portable barcode readers and/or radio-frequency identification scanners to reduce the scope for error
Develop tools to encourage alignment of prescribing practice with clinical guideline

Data standards

Review and re-develop the Australian National Haemovigilance Data Dictionary
Provide tools for hospitals on the application of Australian National Haemovigilance Data Dictionary and reporting of haemovigilance data
Continue to include donor vigilance data in national haemovigilance reporting

Reporting capacity

Conduct a scoping exercise for a national haemovigilance system
Maintain and improve existing capacities for haemovigilance data reporting.

National blood quality and safety initiatives

Haemovigilance has become a more routine part of clinical practice in Australia. The data to date suggests a focus on those events that are most common (FNHTR and severe allergic reactions) and that cause the greatest numbers of severe patient outcomes (FNHTR, severe allergic reactions, TACO, anaphylactoid reactions).

In relative terms, the data suggests that TACO and TRALI, adverse events which account for disproportionate numbers of life threatening and severe morbidity events, are greatly under-reported. However, in overall terms it could be said that most reactions are probably under-reported, with the possible exception of ABO incompatible transfusion events which are sentinel events.

National quality and safety initiatives should aim to support clinical staff to recognise and manage these events, in order to minimise outcome severity for patients, and also to encourage full reporting of these events to increase visibility within transfusion practice. Haemovigilance activities should also clearly prioritise reporting of those adverse events where reporting may alter outcomes for future patient cohorts.

**Table** **34:** Recommendations on national blood quality and safety initiatives
	Recommendation	Who is Responsible	Strategy	How that will be measured
1	Promote the recognition and management of transfusion-related adverse events	NBA; JBC; State and territory Departments of Health; Hospital educators; Relevant professional Colleges and Societies	The NBA will develop and publish a document 'Guidance on Recognition and Management of Acute Transfusion-Related Adverse Events'	Publication and distribution of 'Guidance on Recognition and Management of Acute Transfusion-Related Adverse Events' Conduct an evaluation on the implementation of the guidance document
2	Implement programs at the national, state and local hospital levels to improve reporting of serious adverse events	NBA; JBC; State and territory Departments of Health; Hospital educators; Relevant professional Colleges and Societies	The NBA and HAC will continue to engage with state and territory Departments of Health, hospital educators, and relevant professional Colleges and Societies as part of the ongoing Haemovigilance and Stewardship programs The outcomes for Recommendations 6, 9 and 10 will also contribute to improving reporting of serious adverse events	Publication and distribution of 'Guidance on Recognition and Management of Acute Transfusion-Related Adverse Events' Increased rates of reporting

Reducing human errors

Human errors continue to contribute significantly to transfusion-related risks to patients. Further effort is required to ensure clinical staff comply with national guidelines on the collection and administration of blood and blood products. Data on 'near miss' events (an adverse event that is discovered before the start of a transfusion) would be useful to focus efforts to reduce human errors, and transfusing facilities are now required by NSQHS Standard 7 to record near miss events in haemovigilance data. Research suggests that technological adjuncts such as portable barcode readers and/or radio-frequency identification scanners also reduce the scope for human errors. Clinical staff should also be supported in their efforts with tools such as a defined blood order/prescription form to encourage alignment of prescribing with clinical guidelines.

**Table** **35:** Recommendations on reducing human errors
	Recommendation	Who is Responsible	Proposed Strategy	How that will be measured
3	Clinical staff should comply with national guidelines on sample collection and administration of blood and blood products	State and territory Departments of Health; Hospitals	Hospitals should ensure staff include regular Continued Professional Development to revise; ANZSBT Guidelines for the Administration of Blood Products ANZSBT Guidelines for Pre-Transfusion Laboratory Practice	The number of avoidable human errors should decline
4	Promote the application of technological adjuncts such as portable barcode readers and/or radio frequency identification scanners to reduce the scope for error	NBA; HAC; Quality and Safety organisations; Research Bodies	NBA and jurisdictions to continue to support the research and use of barcode technology and patient safety-software to improve the bedside check of patient, blood and blood product identifications	The NBA will recommend strategies, and/or develop case studies and/or promote the use of: 2D barcode technology and electronic devices to assist with patient bedside safety checks Electronic prescription technologies
5	Develop tools to encourage alignment of prescribing practice with clinical guidelines	NBA; Blood Sector stakeholders	NBA to collaborate with relevant stakeholders to develop a national reference set of tools to assist with transfusion practice	Publication and distribution of tools Conduct evaluations of the implementation of tools

Data standards

The data standards should be revised and updated as haemovigilance matures in Australia. Donor vigilance has been conducted by the Blood Service for many years; however, the HAC is pleased to include the data in the national report for the first time. The ANHDD will be revised and redeveloped, and details of this data dictionary and its use will be communicated directly to hospitals to help them with their haemovigilance activities.

**Table** **36:** Recommendations on data standards
	Recommendation	Who is Responsible	Proposed Strategy	How that will be measured
6	Review and re-develop the Australian National Haemovigilance Data Dictionary	HAC; NBA	HAC to endorse a revised data dictionary and definitions	Publication and distribution of revised ANHDD
7	Provide tools for hospitals on the application of Australian National Haemovigilance Data Dictionary and reporting of haemovigilance data	NBA; State and territory Quality and Safety Units; Hospital Administrators	NBA to inform hospitals on the availability and use of ANHDD NBA to support hospitals to provide a minimum set of data in a spread sheet or other tool for the national haemovigilance reporting	The number of public and private facilities submitting data to the National Haemovigilance Program will increase
8	Continue to include donor vigilance data in national haemovigilance reporting	Blood Service; NBA	Blood Service to continue to improve the transparency of donor vigilance data	Donor vigilance data will continue to be included in future national haemovigilance reports The Blood Service will continue to publish and report on donor vigilance data regularly

Reporting capacity

The mechanisms to collect, record, review and analyse haemovigilance data in Australia are fragmented. This allows varied approaches to data definitions and data validation processes, and has seen haemovigilance reporting develop at different rates in states and territories.

The NBA, assisted by state and territory haemovigilance systems and the JBC, is conducting a scoping exercise to determine the feasibility of a national haemovigilance system to which all transfusing facilities would report their data directly. The results of this exercise will be considered by the JBC in 2013-14. While this feasibility study is underway, states and territories should continue to maintain existing systems and improve capacities for haemovigilance data reporting.

**Table** **37:** Recommendations on reporting capacity
	Recommendation	Who is Responsible	Proposed Strategy	How that will be measured
9	Conduct a scoping exercise for a national haemovigilance system	NBA; HAC; State and territory Departments of Health; Blood Service; Hospitals; Pathology providers; JBC	NBA to work in collaboration with state and territory health departments to investigate the feasibility of establishing a national haemovigilance system	NBA's scoping exercise for the national haemovigilance system will be considered by the JBC in 2013-14
10	Maintain and improve existing capacities for haemovigilance data reporting	NBA; HAC; States and territories; Blood Service; Hospitals; Pathology providers; JBC	States and territories to consider means to improve existing mechanisms for reporting haemovigilance data	The number of public and private facilities submitting data to the National Haemovigilance Program will increase