Transfusion Safety Officers Across the Borders
By Jay Pennington

Over the last several years, infectious risks of transfusion have given way to noninfectious transfusion reactions and procedural errors as the greatest safety concerns for the recipient. Also for many years, quality systems have been in place to reduce errors and near misses throughout the health-care arena, and European and Canadian adverse event reporting systems have helped track where improvements are needed, along with US studies. Still, a substantial number of mistakes continue to be found in the handling of blood between blood bank and bedside. What more can be done?

Enter the transfusion safety officer (TSO), a new position that has emerged in the field of transfusion medicine within the last decade. TSOs attempt to address this stubborn area of pitfall by examining organizations for signs that could lead to unsafe practices and by implementing appropriate action. An integral part of the provincial health system in Quebec since 1999, TSOs or transfusion nurse specialists are slowing becoming more prevalent in the United States. Responsibilities, in general, are similar in the two countries:

·          Quality oversight of transfusion therapy.

·          Compliance with standards.

·          Liaison role.

·          Investigation and reporting of transfusion reactions.

·          Audits.

·          Reports.

·          Preventive and corrective action.

·          Bedside consultation.

·          Staff, patient, and family education.

·          Safety technology implementation.

The session “Transfusion Safety Officers: US and Canadian Perspectives” (9105-TC) was an excellent opportunity to learn more about this emerging field as TSOs from Washington state, New Hampshire and Quebec compared notes about the job.   

Overview of TSOs in the United States

Jeffrey Wagner, BSN, RN, from the Swedish Medical Center and Virginia Mason Medical Center in Seattle, introduced the topic by referring to research published in 2003 that pointed up the importance of noninfectious risks and of an emerging role for TSOs. Although the position still represents a relatively new idea, Wagner estimated there are around 15 TSOs in the United States, six of whom are located in the Seattle area (because of Puget Sound Blood Center’s centralized network). Nevertheless, he emphasized, many nurses or technologists have essentially been performing the role without the title for many years.

In looking to the future, Wagner sees an important opportunity for TSOs to collaborate with the more numerous blood management coordinators, who work in some hospitals to seek and implement alternative strategies to transfusion where possible and appropriate. Blood management coordinators and TSOs share many basic concerns and could complement each other’s goals, he felt.

Wagner noted that the US Biovigilance Network represents an emerging sphere of influence for TSOs, and a Web site in development for the American Association of Transfusion Nurse Specialists and Transfusion Safety Officers will offer important networking opportunities.

US Perspective: Bench to Bedside

The US TSO must ensure that the quality systems of the transfusion service reach to the clinical area, “taking quality assurance from bench to bedside,” explained Kim Maynard, RN, BSN, OCN, Transfusion Safety Officer at Dartmouth-Hitchcock Medical Center (DHMC) in New Hampshire. The TSO at DHMC is a liaison between the laboratory or transfusion service and the nurses and physicians who administer blood components to ensure safety is addressed at all stages of administration.

At DHMC, the position was incorporated before the quality assurance coordinator in the transfusion medicine team retired, but now the TSO has some quality assurance duties, including quality oversight of the blood donor and cellular therapy programs. Thus, there was no need for another staff person, and quality assurance is still applied in all areas of the transfusion service, as it was before. The TSO at DHMC reports to the transfusion service supervisor and medical director.

As one example of safety measures implemented under her supervision at DHMC, Maynard described a mechanical barrier system that reduces identification errors in matching patient, sample and unit. With the Bloodloc (Novatek Medical, Greenwich, Conn.) system, a three-letter code is taken from the patient’s wristband and applied to the patient sample. When the blood bank issues an appropriate unit of Red Blood Cells, a plastic lock is placed on the blood bag, which can be opened at the bedside by checking the patient wristband again and entering the correct code. This system represents one way to reduce misreading or other operator error as blood passes through multiple hands in the hospital.

Maynard recognized that TSOs are on a new threshold in transfusion medicine and concluded by encouraging all TSOs to participate in the TSO network now forming. As she noted, sharing among colleagues is useful to discover best practices and set benchmarks. In Canada, where TSOs have been organized much longer, a Web site and mailing list already link all TSOs to enable them to seek help from and learn from each other.

Quebec Perspective: A Model of Collaborative Efforts

Representing the “home team” of TSOs, Anne-Marie Martel, RN, and Ginette Labonté, RN, from Charles LeMoyne Hospital in suburban Montreal explained how the TSO experience translated to the health-care infrastructure in Quebec.

The position of TSO was created in Quebec by 1999, after a revamping of the entire blood services system, to oversee transfusion practice from both clinical and technical perspectives. Additional related duties were added to job descriptions for other nurses, technologists and hematologists who collaborate with the TSOs.

The transfusion safety initiative involves a contract between facilities (specialty hospitals and regional hospitals with a blood bank) that allows them to enter a communication web of TSO teams, safety collaborators and government agencies. Teams of professionals that focus on transfusion safety include 1) a hematologist, with a leading, supervisory role; 2) a clinical TSO, who handles such things as adverse event reporting, look-backs, recalls and informed consent; and 3) a technical TSO, who, in addition to sharing some responsibilities of the clinical TSO, manages component inventory and leads implementation of the blood bank computer system. Such a team provides the communication link to Quebec’s hemovigilance system, to Hema-Quebec (provincial blood management agency), and the provincial health-care agency.

Every facility that handles blood is linked to at least one TSO or, more frequently, one clinical and one technical TSO. There are 52 TSOs in Quebec: 24 clinical, 23 technical and 5 who are both. This presentation focused on the role of the clinical TSO.  “The clinical TSO acts as a regional pilot for the clinical activities in transfusion medicine within his or her allocated centers,” said Martel. TSOs work to harmonize policies and procedures among facilities. In Quebec, the role of the clinical TSO may be filled by a nurse or medical technologist. The clinical TSO has nursing partners, external partners and organizational partners such as the nursing department, blood bank director, Hema-Quebec and pharmaceutical companies.

RIAT, the Quebec hemovigilance software, facilitates the reporting of adverse events and most Quebec hospitals have access. When it went live in 1999, the Ministry of Health had established guidelines for reporting, but each center was free to follow or amend them. Those guidelines were officially revised to adjust criteria for some adverse reactions, allowing for focus on the more serious ones. As the resource person for adverse events, the clinical TSO is the person who investigates patient files in such cases.

The Quebec Hemovigilance Committee announced that for 2005-2006, there were 4179 reports of adverse events from 77 facilities. Reports of adverse events rose steadily since the implementation of the hemovigilance program, increasing fourfold from 2000 to 2005. However, the increase over the years is a result of better recognition, not an actual increase in events, explained Labonté. One element of the program that has been credited with improving transfusion practice is a section of the patient file (sommaire transfusionnel) in the Quebec blood bank computer system where providers can readily see the patient’s transfusion records.

Clinical TSOs have undoubtedly improved the practice of transfusion medicine, says Labonté; nonetheless, technology is the other essential element in improving transfusion safety. “More than 30% of reported incidents are associated with human errors that could be prevented by electronic identification of recipients.” Hence, one important focus for the future of transfusion practice in Quebec is an electronic identification system for recipients, as well as a certification program for health professionals in transfusion medicine and provincial standardization of policies and procedures in transfusion.

The Transfusion Safety Officer in Canada and the United States

 
Return to Main Menu