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 Safety and Quality Improvement Guide 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.
| 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 (Admin, HTC or equivalent) |
NBA to promote or provide tools that allow states and territories to ensure hospitals have policies, procedures or protocols that adhere to national guidelines such as ANZSBT Guidelines for the Administration of Blood Products and Guideline for Pre-Transfusion Laboratory Practice The NBA to promote or provide tools that enable hospitals to ensure staff include regular continued professional development as part of their program, through resources such as BloodSafe eLearning Monitor and publish the number of human errors in national or state/territory reports |
Human errors captured and published in national or state/territory reports Decrease in the number of avoidable human errors |
| 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; hospitals |
Implement the National Policy on Barcoding for Blood and Blood Products NBA to recommend strategies and develop case studies to support the implementation of the Barcoding Policy |
The Barcoding Policy revised and published on the NBA web in 2014–15 Strategies and case studies developed for the implementation of the Barcoding Policy in 2015–16 Increased use of 2D barcode technology |
| 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 and clinical decision support | Tools developed, published, distributed and evaluated on an ongoing basis |