Patient safety


and can improve team morale by involving and valuing everyone’s opinion. It also provides a holistic approach to safety, combining Safety-II along with Safety-I. There are many ways to incorporate ACE into routine procedures, some of which are shown in Figure 5.


Systems thinking and human factors in process design Systems for healthcare delivery should be present which all healthcare professionals and patients can rely upon. However, transfusion errors reported to SHOT are often caused by faulty systems, processes, and conditions that lead people to make mistakes, therefore these are the areas to be focused upon when seeking to reduce errors and increase excellence. If we consider these factors when designing systems and put the people at the heart of the process, the processes should naturally perform in a way which is beneficial to its users. These interventions require the support from senior management and healthcare leaders. Figure 6 shows the many different factors to consider when designing systems for safe transfusion.


Conclusions A systems-thinking approach is beneficial when forming corrective and preventive actions to improve transfusion safety. This should include learning from adverse events, everyday occurrences, and excellence. Where there are areas of interest and improvement within organisations, a tool such as the SHOT driver diagram7


systems which feed into this. This can be used to direct investigations to the


right pressure points and may uncover potential solutions. The SHOT driver diagram to help identify tactical change ideas to enhance transfusion safety is aimed at the outcomes of the 2022 Annual SHOT Report; however, the concept may be useful within individual organisations. The 2022 Annual SHOT Report shows that there


are improvements to be made in transfusion safety, and that the solutions to these are wider than the individual. The report also shows that those working in healthcare are imaginative, hardworking, and caring individuals who seek the tools to be able to do their best. It takes all of those involved in decision making to be invested in improving systems and working conditions, to improve the safety of staff and patients.


blood components


Safe, reliable and ade- quate supply


The right systems


Space, equipment, financial resources, staffing and safety culture


Transfusions


The right approach


Patient-centred approach, good communication and good patient experience


The right processes


Policies and processes in place to ensure


prompt assessments, access to diagnostic and specialist services


Fig 6. System factors contributing to safer transfusions and healthcare systems.


2. Serious Hazards Of Transfusion. Central Alerting System: Preventing transfusion delays in bleeding and critically anaemic patients. MHRA 2022 (https://www.cas.mhra. gov.uk/ViewandAcknowledgment/ViewAlert. aspx?AlertID=103190)


3. British Society for Haematology. Guidelines for investigation and treatment of acute transfusion reactions. BSH 2023 (https://b-s-h.org.uk/guidelines/ guidelines/guideline-on-the-investigation-and- management-of-acute-transfusion-reactions)


may be useful to help identify the many


4. BCSH Milkins C, Berryman J, Cantwell C, et al. Guidelines for pre-transfusion compatibility procedures in blood transfusion laboratories.


SCAN ME decision-making


Assessing risks and benefits, critical thinking in decision-making


The right Safe


The right personnel


Trained, qualified and competent staff both clinical and laboratory


The right


Transfus Med 2013;23(1):3-35. https://b-s-h.org. uk/guidelines/guidelines/pre-transfusion- compatibility-procedures-in-blood- transfusion-laboratories 5. Cain L. and the HaemSTAR collaborators. The ‘ Two Sample Rule’ in Emergency Departments: a UK-wide survey of junior doctors/physician associates. Oral abstracts book BSH23-OR26. Br J Haematol. 2023;201:4-27. https://doi. org/10.1111/bjh.18718 6. SHOT UK Collaborative Reviewing and reforming IT Processes in Transfusion


(SCRIPT). Using information technology for safe transfusion. SHOT 2023 (https://www. shotuk.org/wp-content/uploads/myimages/ SHOT_Using-Information-Technology-for-Safe- Transfusion.pdf)


7. Serious Hazards Of Transfusion. Driver diagram to help identify tactical change ideas to enhance transfusion safety. SHOT 2023. (https://www. shotuk.org/wp-content/uploads/myimages/ SHOT-Driver-Diagram_ A3@100pc-Landscape_ v5.pdf)


About the authors


Victoria Tuckley is a registered Clinical Scientist and Biomedical Scientist. She has previously worked within red cell immunohaematology and stem cell immunotherapy laboratories, and expanded her motivation for improving the patient experience while working as a transfusion practitioner. She has been a laboratory incidents specialist for Serious Hazards of Transfusion for four years.


CSJ


References 1. S Narayan (Ed), D Poles et al. on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group. The 2022 Annual SHOT Report (2023). https://doi.org/10.57911/WZ85-3885.


50 www.clinicalservicesjournal.com I February 2024


To download the free SHOT App, search SHOT UK in app stores.


To download the full report, visit: http://tinyurl.com/yc3jytjv, or scan the QR code above.


Si Carter-Graham registered as a Nurse in 1989 and has worked in Emergency Departments, Acute Medicine and Medical Assessment. Within NHS Blood and Transplant, he has worked as Area Lead Nurse for blood donation, as a Tissue Donor Co-ordinator and was the National Referral Centre Manager (Tissue & Eye Services). Si has worked as Clinical Incident Specialist in SHOT since 2018.


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