TRANSFUSION SCIENCE


may help reduce errors. Staffing and capacity issues should be on pathology/ laboratory risk registers and reviewed regularly to understand and mitigate their impact on patient safety. A lack of knowledge was reported to be a contributing factor to the error in 159/601 (26.5%) reports compared to 124/535 (23.2%) in 2023. However, most staff involved in laboratory errors were competency assessed (467/601, 77.7%). Incomplete transfusion knowledge in laboratory staff is reflected in the large number of errors occurring at the testing step. Following incidents where gaps in knowledge are identified, appropriate action plans should be put into place to address these and prevent patient harm. It is important that competency assessments cover essential knowledge required to perform the tasks, non- routine scenarios, and seeking advice in complex situations. It may be necessary to perform competency assessments more regularly when the subject is not frequently encountered, staff are inexperienced, have limited time in the laboratory, or work outside of routine hours regularly.


IT was identified as a contributory factor in 329/601 (54.7%) laboratory errors. The most common factors were warning flags not being actioned, 52/329 (15.8%) and lack of functionality/algorithms to support safe practice 47/329 (14.3%). The IBI report (2024) recommended IT to support safe transfusion practices. The


Case study 2 Misunderstanding urgency Platelets were requested for an extremely unwell neonate with a platelet count of 13x109 /L.


The laboratory had no neonatal platelets in stock and notified the clinical team that there would be a five-hour delay in obtaining them from the local Blood Service due to geographical reasons. The patient required transfer to a specialist hospital, and this could not occur until the baby was transfused. Whilst waiting, the patient received other blood components, as disseminated intravascular coagulation was suspected. The medical team queried availability of platelets once again and were notified none were available. A suitable adult therapeutic dose of platelets was available but was reserved for another patient. Following discussions with the neonatal consultant, these were administered to the neonate after a six-hour delay. This caused delay in treatment escalation (central line insertion) and transfer to the specialist hospital, contributing to the death of the patient. The investigation found gaps in communication and misunderstanding of urgency by the laboratory staff. Communication tools were developed by the laboratory for use on the neonatal ward and standard operating procedures were updated to clarify the use of reserved components in an emergency. n SHOT insight 1: In urgent situations where the most appropriate blood components are not available; every effort must be made to ensure a suitable alternative is provided in a timely manner.


n SHOT insight 2: Clear communication is a key aspect of safe patient care. Standard protocols and closed-loop communication may help prevent misunderstandings.


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It may be necessary to perform competency assessments more regularly when the subject is not frequently encountered, staff are inexperienced, have limited time in the laboratory, or work outside of routine hours regularly


17


Ineffective IT 32/120 (26.7%)


Excessive workload


26/114 (22.8%)


Lack of


skills/knowledge 29/112 (25.9%)


Out-of-hours 39/116 (33.6%)


Handover 26/117 (22.2%)


Covering multiple departments 20/91 (22.0%)


Laboratory delays Fig 4. Factors interacting to contribute to laboratory delays in 2024.


SHOT UK collaborative reviewing and reforming IT Processes in Transfusion (SCRIPT) group have created templates and guidance for using IT. Organisations are encouraged to access these resources to support their own planned or current use of IT.


n Laboratory delays in transfusion Laboratory delays increased significantly in 2024, from 56 in 2023, to 120 in 2024, with most errors occurring at the component availability step (62/120, 51.7%). In 25/120 (20.8%) laboratory


cases, the delay occurred during a major haemorrhage (MH). A total of 23/120 (19.2%) laboratory delays involved paediatric patients. Delays were mostly due to incomplete/ inaccurate communication (43/120, 35.8%), gaps in knowledge (28/120, 23.3%), technical problems (eg IT downtime, non-functional equipment) (24/120, 20%), and excessive workload (15/120, 12.5%). There are many factors which contribute to a delay in transfusion, and the laboratory factors are shown in Figure 4.


Lone working 31/95 (32.6%)


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