Noncompliance with the Blood Transfusion Documentation Process in the Coronary Care Unit

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Executive Summary

The paper on noncompliance with the blood transfusion documentation process has five main sections. “Introduction” briefly describes the organization’s problem, and the “Quality Indicator” section covers the details of the process associated with the issue and its relevance. “Nurses’ and Leaders’ Roles” explains how employees of different levels affect the indicator and its improvement. The “Plan for Improving Care” section analyzes the risks associated with noncompliance to the documentation process, the factors contributing to it, and the experience of patients and staff. Finally, this section suggests methods based on research that can be applied to improve the situation. The last section, “Implementation Plan,” deals with the tasks that the hospital may face, distributed according to the elements of implementation – organizational culture; leadership; networks and communication; resources; evaluation, monitoring, and feedback; and champions.

Introduction

Blood transfusion is a vital procedure in hospital conditions, and it requires professional training. The need for a process may arise in case of severe blood loss or in case of disease, due to which some of the blood cells are poorly produced. All steps of the procedure include filling in the documentation by the staff to avoid errors and confusion. However, a problem of noncompliance with the blood transfusion documentation process appeared. The issue brings risks to patient safety and the effectiveness of the organization. To solve it, this paper proposes a few methods that can be applied in the hospital. Several research papers were studied – about the challenges in the process of filling out documents (1-4), the influence of specific factors on the work of medical staff (5-8), and elements necessary for the implementation of changes (9). Even though problems in the transfusion procedure are infrequent, they still require careful attention.

Quality Indicator

Blood transfusion is a procedure for infusing blood given by another person – a donor, to a patient through a tube in the vein (intravenously). Whole blood or its components and derivatives such as plasma, red blood cells, or platelets can be used for this purpose. To ensure the safety of patients, each stage of the procedure must be accompanied by specific documentation. For example, before transfusion, it is necessary to ensure that the blood is compatible, that the process is required, and informed consent is taken. Transfusion itself and observation later also have the required documents. The error of filling any of them can lead to complications and poor health. For this reason, the work focuses on noncompliance with the blood transfusion documentation process.

Nurses’ and Leaders’ Roles

Depending on the treatment stage and the transfusion procedure, documents can be filled out by various medical staff – doctors and nurses of specific shifts. The central role in the management, organization and optimization of all processes belongs to health leaders. Each party can influence the implementation of documentation rules. Leaders’ role in improving care and addressing the problem is to introduce necessary and safer changes to hospital policies and regulations. They must choose the method and strategy for implementing changes and provide the opportunities required for this – training and time. Employees, in particular nurses, for their part, should constantly learn and remember the safety of patients and be guided in actions by the hospitals’ rules. They can also make their suggestions based on evidence-based research to solve the problem.

Plan for Improving Care

Reasons

Noncompliance with the documentation process while the transfusion leads to errors. If problems in the documentation were noticed before transfusion, neglect of the rules creates an organizational problem. Checking results, collecting information from the patient, or additional tests take away employees’ time. In conditions of constant shortage of time, this mistake is critical since less attention is devoted to the patient’s recovery. An example of an error with serious consequences for patients due to staff’s fault is an infusion of incompatible blood. As a result, the patient’s condition deteriorates, and complications appear. The most common adverse reaction that may occur is allergy. More rare and severe reactions are – an overload of the circulation, lung damage, acute hemolytic reaction, and other problems.

Factors Contributing to the Poor Performance

Whether adversely affected or prevented, any error must be investigated, and measures should be taken to eliminate the factors that lead to it. Factors that can affect the work process, in particular documentation, vary. They include lack of staff, work under pressure, lack of experience and knowledge, lack of clear checklists, forgetfulness, and other problems. For example, Algora et al. (1) combine most of these causes into several groups: communication, people, method, management, process, and environment. In this paper, the improvement method focused on eliminating the hospital’s most relevant factors is proposed. Their list includes insufficient communication between employees, lack of training, and forgetfulness. The reasons for noncompliance identified are related to human influence and inadequate management.

Patient Experience

Medical services are focused on the patient’s health and needs. Any mistakes, staff uncertainty, and especially complications lead to patients’ dissatisfaction and the hospital’s negative image. As mentioned, among the adverse consequences are allergies, acute hemolytic reaction, fever, and other complications. As demonstrated by various studies (2, 3), the percentage of errors made during transfusion is not significant. However, even the probability of error or mismatch of documentation leads to a negative patient experience.

Healthcare Personnel (HCP) Experience

In clinical practice, a patient’s life and health depend on the actions of a whole team, including representatives of various medical professions. The more people involved in the patient’s treatment, the more likely the critical medical information will be missed at some of the medical care stages. Most of the hospital staff received education and practical experience in various places. For this reason, everyone has their skills, and for each procedure, some details may differ. Employees note that contrasting experiences, reluctance to be wrong and uncertain hierarchy are the factors that prevent effective communication and cooperation. Under conditions of high workload and stress, fatigue also affects mindfulness and leads to forgetfulness. At the same time, fear can prevent personnel from reporting an error and investigating it.

Method for Improvement

A few most appropriate actions were identified based on the research of similar problems and issues of compliance with rules and standards. This paper proposes several measures to eliminate factors contributing to noncompliance with the blood transfusion documentation process:

Main measures: conducting training regularly for doctors and nurses. Training following the hospital rules will contribute to developing appropriate skills and responses for protocol action (2, 4, 5). Moreover, joint training provides opportunities for better communication between employees and the establishment of working relationships.
Additional measures: creating a single guiding document with instructions for doctors and nurses, its distribution; checking and, if necessary, transforming the checklist on the essential preparations; a collection of records at critical points (4). The need to act following uniform standards established in hospitals and access to additional materials and documents will reduce the likelihood of disputes.
General recommendations: improving working conditions for retaining employees. The retention requires timely payments, training, timely response to complaints and similar problems, adequate burden sharing, and other measures. Such measures can prevent personnel burnout and help them to perform better (6, 7). The steps taken will be useful not only to the retention of employees but also to their satisfaction with the work, commitment to the hospital, and, therefore, higher compliance.

Implementation Plan

The implementation of any changes in the organization depends on the context and features of the operation. Key elements affecting the quality of work and the ability to adopt innovation are interrelated (9). Thus, the implementation plan for changes is presented through organizational culture, leadership; networks and communication; resources, evaluation, monitoring, and feedback; and champions. Each of them has weaknesses and strengths, potential obstacles, and responsible parties.

Organization Culture

Organizational culture requires the following changes:

Introduction of uniform standards for compliance with the blood transfusion documentation process.
Encouraging work on errors.
Increasing level of job satisfaction.

The hospital’s organizational culture encourages ongoing learning and change that leads to more effective work, which is the main strength. However, it is necessary to develop employees’ desire to work on errors despite the fears of failure since this is the main limitation (8). The responsibility lies with the leaders who offer changes, champions that teach and demonstrate an example, and employees who are open to change and ready to improve the quality of care for patients. Shifts in culture do not occur at a rapid pace, and therefore, it may take about six to twelve months for personnel to get used to them.

Leadership

Leaders must:

Select educators and assign a schedule for training that may take several months.
Organize the preparation and distribution of a document with uniform rules – the task takes several weeks.
Promote healthy working relationships and encourage the retention of talented staff. These tasks require continuous work, collaboration with the HR department, analysis, and improvement.

The strengths of the hospital administration as leaders are their motivation for work and improvement and also a concern for patients’ well-being. However, they sometimes face limitations, in particular, the resistance of some employees to change. To implement the plan in this case, the leaders should focus on the champions’ efforts. Leaders are also responsible for allocating the resources needed for both hospital operations and change.

Networks and Communication

Challenges in this area include:

Dissemination of information on uniform standards for blood transfusion documents, training, and educational materials. To increase personnel commitment, it is also essential to report various aspects of work – opportunities, new rules, or news. The creation of information and its dissemination can occur in a few weeks.
Building trust between employees to improve communication and teamwork – as a change in culture takes several months.

Poor communication is one of the critical factors for the appearance of the discussed problem of noncompliance, and for this reason, work on it is essential. The person who will conduct the training may also include special exercises to increase trust among workers. The hospital’s strengths are the existing information dissemination system, which does not need to be improved at the moment. Responsible parties for the tasks are leaders, employees, and trainers.

Resources

The responsible party for the distribution of resources – is the administration of the hospital. Strengths are the support of sponsors and leaders’ ability to dispose effectively of the available resources. Restrictions at the same time are the limitation of all resources. The introduction of changes will require the following resources:

Financial – for support of a system of information dissemination, salary to the trainer, granting necessary materials, and other needs. Constant resources are also required for doctors’ salaries, financial incentives, hospital development, and other requirements.
Personnel and time – trainer are necessary for providing the educational program. Moreover, it demands allocation of time and change of the schedule for employees.
Educational resources – training materials and also documents are necessary.

Evaluation, Monitoring, and Feedback

After training and applying additional measures, the administration will have to assess the effectiveness of the work done. To do this, they need to evaluate:

Readiness for compliance with the blood transfusion documentation process;
Percentage of errors in filling out blood transfusion documentation;
Trust, cooperation, and communication between employees.

The administration may entrust the finding information and its analysis for results to a team of employees. Simultaneously, doctors and nurses are responsible for providing honest feedback about the measures taken. The application of different assessment methods is itself a strength of the hospital, and the potential limitation is the workers’ reluctance to feedback and cooperation. The assessment can be performed several times – immediately after training, after half a year, and after a year to better understand the long-term effects.

Champions

Champions are agent employees who promote and support the implementation of changes, helping to get used to it. At the same time, the next aspects are crucial:

Administration should choose and support responsible champions;
Champions should show perseverance if necessary and defend their position.

The responsibility lies with the administration and those employees who will be chosen as champions. They must be selected when the educational materials will be developed and work while the necessary measures are applied. The advantage is that champions will help introduce changes faster. When loaded, the potential weakness is that both the administration can forget about supporting champions and champions about promoting the idea.

References

Algora M, Grabski G, Batac-Castro AL, Gibbs J, Chada N, Humieda S, et al. Challenges in establishing a transfusion medicine service: The Cleveland Clinic Abu Dhabi experience. Archives of pathology & laboratory medicine. 2018; 142(10):1233-1241.

Moiz B, Siddiqui AK, Sana N, Sadiq MW, Karim F, Ali N. Documentation errors in transfusion chain: Challenges and interventions. Transfusion and Apheresis Science. 2020;59(4):102812.

Hensley NB, Koch CG, Pronovost PJ, Mershon BH, Boyd J, Franklin S, et al. Wrong-patient blood transfusion error: Leveraging technology to overcome human error in intraoperative blood component administration. The Joint Commission Journal on Quality and Patient Safety. 2019;45(3):190-198.

Mora A, Ayala L, Bielza R, Ataulfo Gonzalez F, Villegas A. Improving safety in blood transfusion using failure mode and effect analysis. Transfusion. 2019;59(2):516-23.

Price S, Reichert C. The importance of continuing professional development to career satisfaction and patient care: meeting the needs of novice to mid-to late-career nurses throughout their career span. Administrative Sciences. 2017;7(2):17.

Patel RS, Bachu R, Adikey A, Malik M, Shah M. Factors related to physician burnout and its consequences: a review. Behavioral sciences. 2018;8(11):98.

Farid M, Purdy N, Neumann WP. Using system dynamics modelling to show the effect of nurse workload on nurses’ health and quality of care. Ergonomics. 2020;63(8):952-964.

Rodziewicz TL, Hipskind JE. Medical error prevention. Treasure Island: StatPearls. 2018.

Li SA, Jeffs L, Barwick M, Stevens B. Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review. Systematic reviews. 2018;7(1):1-9.

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