1284 / Preventing AB0 incompatibility errors

ITALY
Classification of the PSP
Type of Patient Safety Practice Not Evaluated
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Blood / Blood products
Patient identification There is no specified text here
Topic of the reported practice
Clinical risk management
Aim and the benefit of the Patient Safety Practice
 
The transfusion reactions from blood incompatibility (ABO) is a dramatic adverse event and is always due to error. This error is a sentinel event (adverse event of particular gravity that can result in death or serious harm to the patient) that can and should be prevented through the use of procedures of proven effectiveness by reducing the risk factors that can determine the occurrence. Its important to prevent incompatibility during the various stages of the transfusion process, from sample collection to determine the blood type of the recipient until the transfusion of blood components. In transfusion process critical stages that may generate the error ABO are summarized as follows: 1) sample collection pre-transfusion in the ward; 2) conduct of investigations immunohaematological; 3) selection and award of blood component transfusion in the structure; 4) monitoring of the infusion and transfusion in the ward. Keywords: transfusion reaction, action for improvement, monitoring, adverse event procedures.
Description of the Patient Safety Practice
 
A procedure for patient identification before collecting specimens to assess blood group and before blood transfusion, has been implemented in 2011. In 2013 we introduced a specific check list for blood transfusion process. Periodic (twice a year) casual review of clinical reports to evaluate the check list compilation rate are carried out. Currently compliance with the checklist is >85%.
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
There is no specified text here
There is no specified text here
There is no specified text here
Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
No
A baseline measurement before implementation of the reported practice was obtained
No
A measurement after full implementation of the reported practice was obtained
Yes
Evaluation of a "positive" effect of the reported practice on Patient Safety
Not relevant
Type of before-and after evaluation
Not relevant
Enclosure of a reference or attachment in case of published evaluation's results
There is no specified text here
There is no specified text here
Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Yes
Specification of implementation in another health care setting(s)
Home care
Successful implementation's level  of this Patient Safety Practice across settings
Yes, across multiple specialities across different health care settings
Involved health care staff
 
Physicians
Nurses
Clinical manager
Quality manager
Risk manager
Other or not relevant
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
No
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
There is no specified text here
Point of time in which service user or their reprasentatives' involvement takes place
There is no specified text here
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
There is no specified text here
Short description of the service users' level of involvement
There is no specified text here
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
Yes
List of sources where public information is accessible
http://buonepratiche.agenas.it/questionnaire.aspx?id=5172
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
No
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
Yes
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
Not sufficient human resources available
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
There is no specified text here
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here
Contact information
 
Name: Ismaele Fusco
Country: ITALY
Organisation: PRATO
E-mail: ifusco@usl4.toscana.it
Phone: There is no specified text here
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