Using a failure mode effects analysis tool to improve hospital-wide transfusion safety

Background/Case Studies: The transfusion of blood products is a complex process that requires coordination and integration of multiple hospital services. Blood transfusion is a process that is commonly performed yet has a very high-risk profile. After a patient safety event, we sought to evaluate the entire transfusion process and improve our hospital transfusion safety. Study Design/Methods: We established a multidisciplinary hospital team with assistance from the Anderson Learning Center and created a process map for the blood product ordering, preparation, and administration processes for non-emergency uses. We used a Failure Modes Effect Analysis (FMEA) tool to prioritize the highest risk interventions to execute for the improvement work. Three workgroups were created for each main steps of the Blood Administration process: Order, Prepare, and Administer to test and implement the interventions. Run and control charts were used to summarize blood audit compliance over time. Results/Findings: A total of 66 failures were identified on the FMEA with 36 failure modes having a high severity and 13 failure modes with a high Risk Priority Number. The prioritized interventions for this project addressed 74% of the overall failures. Revisions included: (1) Blood order sets to weight-base to protect from inadvertent ordering of units when mL should be ordered;(2) Dual verification process for blood administration and implementation of dual badge verification;(3) Implementation of annual ordering provider blood safety education. A Quality Assurance (QA) and Compliance position with a focus in Transfusion Medicine was approved for transfusion safety oversight. A blood utilization and safety data dashboard with easy access for hospital and unit leaders was also created. Over the course of 120 days of testing interventions, we increased blood administration volume from 12 audits per month (0.8% of our transfusions) to 597 audits per month pre-COVID-19 (36% of our transfusions) and 236 audits per month during COVID-19 (15% of our transfusions). We increased our audit percent compliance from 90.9% to 97%. Volume of blood administration audits did decrease from March 2020 to the present due to patient contact limitations associated with the COVID-19 pandemic. However, the compliance rate of 97% has remained consistent over the last 7 months. Conclusions: An empowered multi-departmental steering team, disciplined use of the failure mode effect analysis tool, high engagement from multiple levels of hospital divisions, and standardized training processes enabled successful implementation of interventions in a short time frame. This approach can assist hospitals in making their blood product administration process more streamlined, more pro-active instead of re-active, and most importantly, safer for patients. Poster Presentations: Therapeutic Apheresis.