Managing errors

[RR1]

I seem to be going through a run of errors in my lab, which involve staff issuing blood components that have the wrong dob / hospital number/ spelling discrepancy in the name (hopefully not all at the same time!!)...but this generally involves 1 letter or number difference.

Since these are reportable to SABRE/ SHOT (UK haemovigilance systems), this is keeping me quite busy at the moment. I have implemented re-training, raised GMP checking awareness etc...but this is not improving matters.

The root cause is possibly inadequate staffing, but whenever I mention this- the common response is ' aren't we all?'.

What else can I do to improve things ? fully electronic PPI is currently out of the equation for at least 2-5 years at my place.

What really worries me is when I read error management articles that make statements such as 'for every 30 minor related errors- you tend to lead upto a major error'.....not something any of us want to see happen.

[Eagle Eye]

You need to train your staff to make sure that they do not process specimens which are not acceptable. We had our share of those errors but with retraining and counseling of each individual we have very few errors.

When it comes to following policy, excuse of "short staff" doesn't fly at my place.

[RR1]

Thanks aakupaku, you are right ...and the staff have had their training, with some of them having individual extra sessions. The mistakes generally involve 1 letter or number difference. It can be a very busy lab - especially during the night shift when one person is trying to balance 45min turn-a-round times for a busy haematology section , together with the transfusion area. This is when most of the mistakes are happening.

This isn't helped by the fact that the numbering and identification sysyem within the hospital needs significant improvements, so that all medical staff know how to obtain correct patient ID to begin with.

We're all human...100% error free will never be achieved, though we can try to aim for it.

[dferia]

Training is always important, with discussion on the implications of the error if it went through undetected (though with single characters off, the chance is low, btu nothing is ever 0, especially not with Murphy's Law). In my experience though, training/knowledge of staff is not really a primary cause of the vast majority of errors. Other thigns you might want to look at are:

1. When the errors began, was there any process change/new implementation that occurred aroudn the same time that may have impacted the process? Changes to the process can lend itself to peoplebeing confused betwene old/new processes and just in general, with people keeping the new activities in mind, lend itself to increases in error.

2. Examine the process overall. Sometimes the process or the paperwork used in the process, is laid out or ordered in a manner that lends itself to an increase in errors. Something might be missing on a form for example. Assuming there has been no process changes (relating to #1 above) and the number of errors were stable previously, this may not be the issue.

3. Related to #1 above, but is there new staff in place in training? That can lend itself to an increase in errors just as much as a new process. Much as we love to think having a new trainee /and/ a mentoring trainer both looking at the work, the impact on the workflow by acting as double duty can sometimes result in errors.

4. Is there a way of adding a new control point to the process? If all the above are not inherently involved in the process, and nothing else is available to reduce the errors, then a control point needs to be in place to catch errors before they become reportable. Add a second review check, electronic verification (if such a thing is possible with the process), etc.

I know these are rather general comments, but hopefully they're not utterly useless.

[RR1]

Thank you dferia, you have mentioned a few points I haven't really looked at. Looking back on some of my incidents, the un-Lean layout of my lab is definately contributing to problems. I suppose if I escalate this as a possible cause -may actually help to secure resources for improvements (at least I can hope!!!).

[dferia]

Glad I can bring up a couple of new items that might help out. Even better if they help get you some needed resources for lab improvement (don't we always hope for that?).

David

[Likewine99]

dferia is correct, if you can examne the overall process there might be a spot to build in some type of extra check, especially at the point where humans enter the process.

If possible have someone in the lab who doesn't work BB, or someone from outside to walk through the process, it is amazing what non-Blood Bankers see, sometimes we are too close to the process.

[Malcolm Needs ☆]

I agree Likewine99, it is often absolutely amazing what non-Blood Bankers see; sadly, they don't always understand!

I would, therefore, recommend that, before those too far removed from the environment of the Blood Bank are invited to give their views, a Blood Banker from "out-of-town"(for want of a better phrase) are invited into the Laboratory (a Reference Laboratory worker into a Hospital Blood Bank and vice versa, someone from an entirely different hospital Blood Bank to your own Blood Bank, someone from an entirely different Reference Laboratory into your own Reference Laboratory, etc).

If you invite in someone who does not understand the fundamentals of transfusion (and, gosh, are there many who do not, but think they do) then that way leads to disaster (or Accrediting Agencies/Quality, as they are sometimes known)!

[RR1]

I agree with you all, but from my experience of our regulators- they have an excellent understanding of these issues, in fact they have been wonderfully helpful in teaching me how to minimise problems, by improving my quality system.

[Malcolm Needs ☆]

Yes RR1, some of them are very good, but a substantial number are very definitely not.

It is, sadly, exceedingly rare to find an inspector, for example, who understands both red cell serology (as opposed to blood transfusion) and Good Manufacturing Procedue (GMP), and of these, they usually understand the GMP far better than the red cell serology. In no way should the two come into conflict, but there are times when we use tests that are very different to the norm, but these individuals (I could name an absolute prime example, but I won't - and that is only on the greounds that I do not want to be sued for every penny I have) completely wreck a system, because they do not have the necessary knowledge, but do have the necessary power.

This is, of course, a total misuse of the power, but you try an appeal!

Edited June 7, 2009 by Malcolm Needs
SPELLING (AGAIN!)

[RR1]

Hi Malcolm,

I'm still going to disagree with you over this, it could be that inspections of blood establishments are slightly different to hospital blood banks. It's the overall process they are looking at not the individual techniques, that's why they don't need to fully understand transfusion serology. GMP in transfusion labs, pharmaceuticals, car manufacturing is virtually the same- maybe slightly different levels.

I get the impression the inspectors are trying to improve what and how you are performing your tests- to ensure robustness, not trying to change what you are doing (unless this is totally going against good practice guidelines).

I think (but I might be wrong!), that they want you ensure a risk assessment has been performed for any practices that are not the 'norm', and to justify what and why you are doing this. Specialist red cell work is different- but you need to show them with a written R.A, that critical points of your varient testing regimes have all been considered.

It could be that we are all over reacting to some of their comments.

Edited June 7, 2009 by RR1

[Malcolm Needs ☆]

We did all of the above and............nothing.

They were right and we were wrong.

We had to abandon our rare donor screening programme for five months. This was a programme that had run for 25 years. Now, I know that in no way means that it cannot be improved or made more robust, but it was 25 years during which there had been NO recorded adverse incidents involving either a donor or a recipient; and one would have thought that, if the system was so bad as to require abandonment for five months, there might just have been one such incident that had come to light.

[Abdulhameed Al-Attas]

where is my post gonne?

Edited June 7, 2009 by Abdulhameed Al-Attas

[Abdulhameed Al-Attas]

where is my post gonne?

where is my post gonne?

[RR1]

We did all of the above and............nothing.

They were right and we were wrong.

We had to abandon our rare donor screening programme for five months. This was a programme that had run for 25 years. Now, I know that in no way means that it cannot be improved or made more robust, but it was 25 years during which there had been NO recorded adverse incidents involving either a donor or a recipient; and one would have thought that, if the system was so bad as to require abandonment for five months, there might just have been one such incident that had come to light.

It does seem a bit extreme, but it's difficult to comment unless we know how the citation was actually worded, and the non-conformance level given to this.

[RR1]

where is my post gonne?

If your post takes too long to compose, you need to copy it, then log yourself back into BBT, paste and submit.

[Malcolm Needs ☆]

Message deleted (see below).

Edited June 7, 2009 by Malcolm Needs

[Malcolm Needs ☆]

It does seem a bit extreme, but it's difficult to comment unless we know how the citation was actually worded, and the non-conformance level given to this.

I'll tell you the full story on Thursday (assuming you are going to the TAG Meeting at Worthing), but you had better prepare your delicate ears for some industrial language. The full story involves the use of a few adjectives I wouldn't usually use in front of a lady (or you)!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

[RR1]

I'll tell you the full story on Thursday (assuming you are going to the TAG Meeting at Worthing), but you had better prepare your delicate ears for some industrial language. The full story involves the use of a few adjectives I wouldn't usually use in front of a lady (or you)!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

can't wait!

[AUDREY]

I have read all the responses.It is true that we all have staffing shortages which probably will not improve in the future.My supervisors state emphatically that errors cannot be blamed on fewer personnel. How many of you have only Blood bankers in your Blood Bank? I have 14 techs, all with varied skill levels and all generalists.The techs fresh out of school are on nights and the techs that have been here the longest are on dayshift.Sound familiar?

How can I keep my generalists up to speed when they may only be in the Blood bank 4- 5 times per month?

[Malcolm Needs ☆]

There will be a paper published fairly soon in the Journal of the British Blood Transfusion Society (BBTS), Transfusion Medicine and also in the Journal of the Institute of Biomedical Sciences (IBMS) The British Journal of Biomedical Science that will, hopefully, put the lie to the idea that errors cannot be blamed on fewer personnel, Audrey, and certainly will put the lie to the fact that those on night duty should be the most inexperienced.

Your supervisors should already know this, if they read the annual report fo the Severe Hazards of Blood Transfusion (SHOT) Reports issued in the UK over the last decade. Although these reports are concerning incidents within the UK, they are extremely relevant to every other country in the world, and your supervisors should (MUST) be up to speed with such reports.

[RR1]

I have read all the responses.It is true that we all have staffing shortages which probably will not improve in the future.My supervisors state emphatically that errors cannot be blamed on fewer personnel. How many of you have only Blood bankers in your Blood Bank? I have 14 techs, all with varied skill levels and all generalists.The techs fresh out of school are on nights and the techs that have been here the longest are on dayshift.Sound familiar?

How can I keep my generalists up to speed when they may only be in the Blood bank 4- 5 times per month?

Hi AUDREY, we all seem to accept that staffing will not improve in the future due to financial constraints, but WHY do we ? All staff need to rotate into transfusion on a monthly basis - this is currently an ideal situation, but should be standard good practice. Part of the time should be spent being trained / re-trained , competency assessed etc.

Until each of us highlights inadequate staffing being the cause of the majority of transfusion lab incidents, we will continue to see individual staff members being blamed when these happen....this is unacceptable.

We need to start a revolution, for the implementation of good, solid, training structures in all transfusion labs.

[dferia]

While I will not argue that there are numerous examples of inspectors/assessors who lack the requisite knowledge to perform an assessment of blood banks and transfusion services (among other things), not to mention there are those who suffer from delusions of godhood given to them by the mantle of authority (and sadly some who suffer both inadequacies at once), there are mirror versions of those individuals in charge of blood banks and transfusion services. Claims of "I know best, I have a degree in (insert whatever degree you want here" is no more valid than, "I know quality better than you".

In my mind, the ultimate goal of any inspection or assessment is the sharing of knowledge, to learn from each perspective to make a better process for the preservation of health of those we provide for. Everyone wants to do the right thing and takes pride in their work, even the incompetent ones (or so I'd like to hope and believe baring evidance to the contrary), and that is the starting point for discussion. Building from that shared kernal, even if it takes a great deal of time and conversation, will usually bring about improvements overall (though there may be some hair pulling and choice colorful phrases along the way, in private or otherwise). Ask for regulatory references, sometimes that gets some of bull out of the way and drops the instances of personal preference and opinion. Ask the inspector for examples of other places they have visited that had the same system that did meet the requirements; why reinvent the wheel if unnecessary? And finally, sometimes you might be able to get an inspector to offer possible suggestions. Will they all work/fit? No, but sometimes things can be tweaked to fit the particular circumstances you work in.

For those cases where the individuals involved are just cmoplete shut away from the concept of reality and buried in the mire of their own personal delusions of grandeur, speak to their superiors. Make formal complaints with specific examples of detailed evidance (and no, "(S)He's an idiot" is not adequate enough much as we'd like it to be). People who rant are usually written off as unhappy ranters without valid claims. Direct evidance though given rationally is harder to ignore in general, and if the evidance comes in from multiple organizations, before too much longer the bad seed is usually offered a different door (not always, but hopefully).

And it never hurts to learn more and expand our knowledge in our industry. BY that I don't just mean the day to day practices in the lab, for those who work in the lab, or the changging regulations for those who are nispectors. Quality and regulations is as much a part of our industry and the lab work and its not going to change. We need to build our awareness of it. Conversely, if you're an inspector, it is just as necessary to gain an understanding of whatever industry it is you are inspecting. It only makes practical sense to do the job right on both sides the first time out and at elast have a conversation that doesn't require translator to get at what the other person is trying to say. Do you need to be an expert, heck no, but a little knowledge goes a long way and gives some impression you care about what you're doing.

Regarding the notion of System X or Y having been in place for however many years, really, I've never seen that statement as anything of value. Tradition is a wonderful song from Fiddler on the Roof, but it is hardly the foundation for keeping a system in place. At one time we used to bleed people, obviously the claim of holding to the practice as acceptable since "we've always done it that way" is hardly a valid one for that practice. Any system, no matter how old, can likely be improved. Technology changes, the practices change, the way we do business changes, nothing in the universe is unchanging (well, except death and taxes). As such, at one point or another, its possible as the situation surrounding anything changes, that the system can be improved, even if it's just a little thing, like adding electronic data entry as opposed to a personal check (or maybe just the opposite if the computer sucks or predates the 80s for instance).

Anyways, enough of my soapbox, I'm sure I've put enough people to sleep by this point. In the end, its just my two cents on the topic and worth it's weight in electrons.

David

[Malcolm Needs ☆]

David, I think everything you say is valid, and I agree that our rare donor screening programme can almost certainly be improved. My problem in this particular case was that the inspector actually admitted that he knew nothing about red cell immunohaematology, admitted that he did not understand the screening programme and still made us change it!

Unfortunately, he was the one who was interpreting the EU Regulations, which are extremely woolly in places, but very precise in others, and he was the lead inspector, so there was nobody to complain to, except a Government Minister!

[RR1]

Hi Malcolm, you obviously had to make changes to carry on with the programme 5 mths later....I presume these were improvements to the system. The length of time it took to make these changes was down to the blood centre not the inspectors.

I agree with what David has written, inspections should be looked upon as ways of improving our systems not criticisms. I have learnt so much from our inspectors in last 16mths, they have been excellent. It is solely how individuals perceive inspections that makes the difference.