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Amon CC, Paley AR, Forbes JA, Guzman LV, Rajwani AA, Trzcinka A, Comenzo RL, Drzymalski DM. Implementing structured handoffs to verify operating room blood delivery using a quality academy training program: an interrupted time-series analysis. Int J Qual Health Care 2021; 33:6213818. [PMID: 33825860 DOI: 10.1093/intqhc/mzab061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/02/2021] [Accepted: 04/06/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Blood transfusion is a complex process at risk for error. OBJECTIVE To implement a structured handoff during the blood transfusion process to improve delivery verification. METHODS A multidisciplinary team participated in the quality academy training program at an academic medical center and implemented a structured handoff of blood delivery to the operating room (OR) using Plan-Do-Study-Act cycles between 28 October 2019 and 1 December 2019. An interrupted time-series analysis was performed to investigate the proportions of verified deliveries (primary outcome) and of verified deliveries among those without a handoff (secondary outcome). Delivery duration was also assessed. RESULTS A total of 2606 deliveries occurred from 1 July 2019 to 19 April 2020. The baseline trend for verified deliveries was unchanging [parameter coefficient -0.0004; 95% confidence interval (CI) -0.002 to 0.001; P = 0.623]. Following intervention, there was an immediate level change (parameter coefficient 0.115; 95% CI 0.053 to 0.176; P = 0.001) without slope change (parameter coefficient 0.002; 95% CI -0.004 to 0.007; P = 0.559). For the secondary outcome, there was no immediate level change (parameter coefficient -0.039; 95% CI -0.159 to 0.081; P = 0.503) or slope change (parameter coefficient 0.002; 95% CI -0.022 to 0.025; P = 0.866). The mean (SD) delivery duration during the intervention was 12.4 (2.8) min and during the post-intervention period was 9.6 (1.6) min (mean difference 2.8; 95% CI 0.9 to 4.8; P = 0.008). CONCLUSION Using the quality academy framework supported the implementation of a structured handoff during blood delivery to the OR, resulting in a significant increase in verified deliveries.
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Affiliation(s)
- Carly C Amon
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA
| | - Adina R Paley
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA
| | - Judith A Forbes
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Leidy V Guzman
- Department of Quality and Patient Safety, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Aliysa A Rajwani
- Department of Quality and Patient Safety, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Agnieszka Trzcinka
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA.,Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, 800 Washington St #298 Ziskind Building, 6th Floor, Boston, MA 02111, USA
| | - Raymond L Comenzo
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA.,Department of Pathology and Laboratory Medicine, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Dan M Drzymalski
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA.,Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, 800 Washington St #298 Ziskind Building, 6th Floor, Boston, MA 02111, USA
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2
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Human Factors and Quality Improvement in the Emergency Department: Reducing Potential Errors in Blood Collection. J Patient Saf 2020; 16:47-51. [PMID: 26895189 DOI: 10.1097/pts.0000000000000237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Adverse events in blood collection procedures such as mismatched or unlabeled samples may have critical implications on patient safety (such as wrong diagnosis and treatments). The current study examined blood collection procedures in an emergency department before and after the application of a human factors approach for improving performance quality and preventing adverse events. METHODS In the emergency department of a community care hospital, 190 blood collection events were observed in 2 phases: preintervention and postintervention. Two quality measures were tested as follows: quality measure 1, performing all 7 stages in the procedure of blood collection according to protocol, and quality measure 2, performing the stages of the procedure in the correct sequence according to the protocol. In addition, medical staff anonymously answered questionnaires about their procedure for collecting blood. RESULTS Analyses of data collected before the intervention revealed only 2 events in which all 7 stages in the protocol of the procedure were performed and only 1 event in which the 7 stages of the procedure were performed in the correct sequence. In 91% of the events, the patient was not fully identified. Based on these findings, we developed an intervention using a human factors approach to improve the quality of performance. Analyses of data collected after the intervention revealed significant differences (t188 = -14.9, ρ < 0.01) in quality measure 1 before (mean [SD], 4.8 [0.6]) and after (mean [SD], 6.4 [0.8]) the intervention was initiated, which implies improvement on efficiency subsequent to the implementation of the intervention. Improvement also appeared in quality measure 2. CONCLUSIONS This study illustrates the nature of potential errors in blood collection performance, offering a proactive approach to improve the rate of proper performance.
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De Ramón Fernández A, Ruiz Fernández D, Sabuco García Y. Business Process Management for optimizing clinical processes: A systematic literature review. Health Informatics J 2019; 26:1305-1320. [PMID: 31581880 DOI: 10.1177/1460458219877092] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Business Process Management is a new strategy for process management that is having a major impact today. Mainly, its use is focused on the industrial, services, and business sector. However, in recent years, it has begun to apply for optimizing clinical processes. So far, no studies that evaluate its true impact on the healthcare sector have been found. This systematic review aims to assess the results of the application of Business Process Management methodology on clinical processes, analyzing whether it can become a useful tool to improve the effectiveness and quality of processes. We conducted a systematic literature review using ScienceDirect, Web of Science, Scopus, PubMed, and Springer databases. After the electronic search process in different databases, 18 articles met the pre-established requirements. The findings support the use of Business Process Management as an effective methodology to optimize clinical processes. Business Process Management has proven to be a feasible and useful methodology to design and optimize clinical processes, as well as to automate tasks. However, a more comprehensive follow-up of this methodology, better technological support, and greater involvement of all the clinical staff are factors that play a key role for the development of its true potential.
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4
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Glisch C, Jawa Z, Brener A, Carpenter E, Gottschall J, Treml A, Karafin MS. Evaluation of a two-sample process for prevention of ABO mistransfusions in a high volume academic hospital. BMJ Open Qual 2018; 7:e000270. [PMID: 30057954 PMCID: PMC6059318 DOI: 10.1136/bmjoq-2017-000270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 06/05/2018] [Accepted: 06/19/2018] [Indexed: 11/17/2022] Open
Abstract
Background Acute haemolytic transfusion reactions due to ABO incompatible blood transfusion remain a leading cause of transfusion-associated morbidity and mortality in the USA. Erroneous patient identification and specimen labelling account for many errors that lead to ABO mistransfusions; these errors are largely preventable. Methods Our hospital requires a two-sample process of ABO/Rh typing prior to transfusion. Both samples must be drawn independently. To prevent simultaneous sample draw, our second sample tube has a unique pink top that is only available from the blood bank and can only be sent to the patient’s floor once the first sample arrives in the lab. We performed an audit of this process from 19 March to 30 July 2014 and 19 March to 30 July 2015. Results We reviewed type and crossmatch orders for 2702 new patients during the audit period and 824 patients (30.5%) required transfusion. All patients evaluated received compatible blood, and no mistransfusions were recorded using this method. Three per cent of testing was performed incorrectly, which safely defaulted to giving type O blood. Conclusions The two-sample protocol used by our institution can decrease the risk of mistransfusion. Our protocol was relatively inexpensive, safe, efficient and practical for adaptation by other hospitals.
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Affiliation(s)
- Chad Glisch
- Internal Medicine, Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Zeeshan Jawa
- Internal Medicine, Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Alina Brener
- Internal Medicine, Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Erica Carpenter
- Internal Medicine, Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Wisconsin Diagnostic Laboratories, Milwaukee, Wisconsin, USA
| | - Jerome Gottschall
- Internal Medicine, Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Medical Sciences Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
| | - Angela Treml
- Internal Medicine, Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Medical Sciences Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew Scott Karafin
- Internal Medicine, Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Medical Sciences Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
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Osterweil LJ, Bishop M, Conboy HM, Phan H, Simidchieva BI, Avrunin GS, Clarke LA, Peisert S. Iterative Analysis to Improve Key Properties of Critical Human-Intensive Processes. ACM TRANSACTIONS ON PRIVACY AND SECURITY 2017. [DOI: 10.1145/3041041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In this article, we present an approach for systematically improving complex processes, especially those involving human agents, hardware devices, and software systems. We illustrate the utility of this approach by applying it to part of an election process and show how it can improve the security and correctness of that subprocess. We use the Little-JIL process definition language to create a precise and detailed definition of the process. Given this process definition, we use two forms of automated analysis to explore whether specified key properties, such as security and safety policies, can be undermined. First, we use model checking to identify process execution sequences that fail to conform to event-sequence properties. After these are addressed, we apply fault tree analysis to identify when the misperformance of steps might allow undesirable outcomes, such as security breaches. The results of these analyses can provide assurance about the process; suggest areas for improvement; and, when applied to a modified process definition, evaluate proposed changes.
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Affiliation(s)
| | | | | | | | | | | | | | - Sean Peisert
- University of California at Davis and Lawrence Berkeley National Laboratory
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6
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Lu Y, Teng F, Zhou J, Wen A, Bi Y. Failure mode and effect analysis in blood transfusion: a proactive tool to reduce risks. Transfusion 2013; 53:3080-7. [PMID: 23560475 DOI: 10.1111/trf.12174] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 01/31/2013] [Accepted: 01/31/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Yao Lu
- Department of Blood Transfusion; Research Institute of Surgery, Daping Hospital, Third Military Medical University; Chongqing P.R. China
- Department of Quality Control; Research Institute of Surgery, Daping Hospital, Third Military Medical University; Chongqing P.R. China
| | - Fang Teng
- Department of Blood Transfusion; Research Institute of Surgery, Daping Hospital, Third Military Medical University; Chongqing P.R. China
- Department of Quality Control; Research Institute of Surgery, Daping Hospital, Third Military Medical University; Chongqing P.R. China
| | - Jie Zhou
- Department of Blood Transfusion; Research Institute of Surgery, Daping Hospital, Third Military Medical University; Chongqing P.R. China
- Department of Quality Control; Research Institute of Surgery, Daping Hospital, Third Military Medical University; Chongqing P.R. China
| | - Aiqing Wen
- Department of Blood Transfusion; Research Institute of Surgery, Daping Hospital, Third Military Medical University; Chongqing P.R. China
- Department of Quality Control; Research Institute of Surgery, Daping Hospital, Third Military Medical University; Chongqing P.R. China
| | - Yutian Bi
- Department of Blood Transfusion; Research Institute of Surgery, Daping Hospital, Third Military Medical University; Chongqing P.R. China
- Department of Quality Control; Research Institute of Surgery, Daping Hospital, Third Military Medical University; Chongqing P.R. China
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Using process elicitation and validation to understand and improve chemotherapy ordering and delivery. Jt Comm J Qual Patient Saf 2013; 38:497-505. [PMID: 23173396 DOI: 10.1016/s1553-7250(12)38066-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chemotherapy ordering and administration, in which errors have potentially severe consequences, was quantitatively and qualitatively evaluated by employing process formalism (or formal process definition), a technique derived from software engineering, to elicit and rigorously describe the process, after which validation techniques were applied to confirm the accuracy of the described process. METHODS The chemotherapy ordering and administration process, including exceptional situations and individuals' recognition of and responses to those situations, was elicited through informal, unstructured interviews with members of an interdisciplinary team. The process description (or process definition), written in a notation developed for software quality assessment purposes, guided process validation (which consisted of direct observations and semistructured interviews to confirm the elicited details for the treatment plan portion of the process). RESULTS The overall process definition yielded 467 steps; 207 steps (44%) were dedicated to handling 59 exceptional situations. Validation yielded 82 unique process events (35 new expected but not yet described steps, 16 new exceptional situations, and 31 new steps in response to exceptional situations). Process participants actively altered the process as ambiguities and conflicts were discovered by the elicitation and validation components of the study. Chemotherapy error rates declined significantly during and after the project, which was conducted from October 2007 through August 2008. DISCUSSION Each elicitation method and the subsequent validation discussions contributed uniquely to understanding the chemotherapy treatment plan review process, supporting rapid adoption of changes, improved communication regarding the process, and ensuing error reduction.
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Whitehurst JM, Schroder J, Leonard D, Horvath MM, Cozart H, Ferranti J. Towards the creation of a flexible classification scheme for voluntarily reported transfusion and laboratory safety events. J Biomed Semantics 2012; 3:4. [PMID: 22607821 PMCID: PMC3431246 DOI: 10.1186/2041-1480-3-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 05/11/2012] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Transfusion and clinical laboratory services are high-volume activities involving complicated workflows across both ambulatory and inpatient environments. As a result, there are many opportunities for safety lapses, leading to patient harm and increased costs. Organizational techniques such as voluntary safety event reporting are commonly used to identify and prioritize risk areas across care settings. Creation of functional, standardized safety data structures that facilitate effective exploratory examination is therefore essential to drive quality improvement interventions. Unfortunately, voluntarily reported adverse event data can often be unstructured or ambiguously defined. RESULTS To address this problem, we sought to create a "best-of-breed" patient safety classification for data contained in the Duke University Health System Safety Reporting System (SRS). Our approach was to implement the internationally recognized World Health Organization International Classification for Patient Safety Framework, supplemented with additional data points relevant to our organization. Data selection and integration into the hierarchical framework is discussed, as well as placement of the classification into the SRS. We evaluated the impact of the new SRS classification on system usage through comparisons of monthly average report rates and completion times before and after implementation. Monthly average inpatient transfusion reports decreased from 102.1 ± 14.3 to 91.6 ± 11.2, with the proportion of transfusion reports in our system remaining consistent before and after implementation. Monthly average transfusion report rates in the outpatient and homecare environments were not significantly different. Significant increases in clinical lab report rates were present across inpatient and outpatient environments, with the proportion of lab reports increasing after implementation. Report completion times increased modestly but not significantly from a practical standpoint. CONCLUSIONS A common safety vocabulary can facilitate integration of information from disparate systems and processes to permit meaningful measurement and interpretation of data to improve safety within and across organizations. Formation of a "best-of-breed" classification for voluntary reporting necessitates an internal examination of localized data needs and workflow in order to design a product that enables comprehensive data capture. A team of clinical, safety, and information technology experts is necessary to integrate the data structures into the reporting system. We have found that a "best-of-breed" patient safety classification provides a solid, extensible model for adverse event analysis, healthcare leader communication, and intervention identification.
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Affiliation(s)
- Julie M Whitehurst
- Duke Health Technology Solutions, Duke University Health System, 2424 Erwin Road, Suite 1201, Durham, NC, 27705, USA
| | - John Schroder
- Duke Health Technology Solutions, Duke University Health System, 2424 Erwin Road, Suite 1201, Durham, NC, 27705, USA
| | - Dave Leonard
- Duke Health Technology Solutions, Duke University Health System, 2424 Erwin Road, Suite 1201, Durham, NC, 27705, USA
| | - Monica M Horvath
- Duke Health Technology Solutions, Duke University Health System, 2424 Erwin Road, Suite 1201, Durham, NC, 27705, USA
| | - Heidi Cozart
- Duke Health Technology Solutions, Duke University Health System, 2424 Erwin Road, Suite 1201, Durham, NC, 27705, USA
| | - Jeffrey Ferranti
- Duke Health Technology Solutions, Duke University Health System, 2424 Erwin Road, Suite 1201, Durham, NC, 27705, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
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de Carvalho RVF, Brener S, Ferreira AM, do Valle MCR, Moraes-Souza H. Transfusion Practices Committee of a public blood bank network in Minas Gerais, Brazil. Rev Bras Hematol Hemoter 2012; 34:416-20. [PMID: 23323064 PMCID: PMC3545427 DOI: 10.5581/1516-8484.20120104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 09/20/2012] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study aimed to verify the performance of blood transfusion committees in transfusion services linked to the public blood bank network of the state of Minas Gerais. METHODS A cross-sectional observational study was conducted between 2007 and 2008 using questionnaires and proficiency tests to evaluate the reporting and investigation of transfusion reactions comparing transfusion services with and without transfusion committees in the public transfusion services of the state of Minas Gerais. RESULTS Nineteen of Hemominas own transfusion services and 207 that contracted the services of the foundation located in 178 municipalities were visited between 2007 and 2008. Established transfusion committees were present in 63.4% of the services visited. Transfusion incidents were reported by 53 (36.8%) transfusion services with transfusion committees and by eight (9.6%) without transfusion committees (p < 0.001) with 543 (97.5%) and 14 (2.5%) notifications, respectively. Of the reported transfusion incidents, 40 (75.5%) transfusion services with transfusion committees and only two (25%) of those without transfusion committees investigated the causes. CONCLUSION The incidence of notification and investigation of the causes of transfusion reactions was higher in transfusion services where a transfusion committee was present. Despite these results, the performance of these committees was found to be incipient and a better organization and more effective operation are required.
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Affiliation(s)
| | - Stela Brener
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Fundação Hemominas, Belo Horizonte, MG, Brazil
| | - Angela Melgaço Ferreira
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Fundação Hemominas, Belo Horizonte, MG, Brazil
| | | | - Helio Moraes-Souza
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Fundação Hemominas, Belo Horizonte, MG, Brazil
- Universidade Federal do Triângulo Mineiro - UFTM, Uberaba, MG, Brazil
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Anders S, Miller A, Joseph P, Fortenberry T, Woods M, Booker R, Slaughter J, Weinger MB, France D. Blood product positive patient identification: comparative simulation-based usability test of two commercial products. Transfusion 2011; 51:2311-8. [DOI: 10.1111/j.1537-2995.2011.03185.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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11
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Levy R, Pantanowitz L, Cloutier D, Provencher J, McGirr J, Stebbins J, Cronin S, Wherry J, Fenton J, Donelan E, Johari V, Andrzejewski C. Development of electronic medical record charting for hospital-based transfusion and apheresis medicine services: Early adoption perspectives. J Pathol Inform 2010; 1:8. [PMID: 20805955 PMCID: PMC2929543 DOI: 10.4103/2153-3539.65345] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 05/25/2010] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Electronic medical records (EMRs) provide universal access to health care information across multidisciplinary lines. In pathology departments, transfusion and apheresis medicine services (TAMS) involved in direct patient care activities produce data and documentation that typically do not enter the EMR. Taking advantage of our institution's initiative for implementation of a paperless medical record, our TAMS division set out to develop an electronic charting (e-charting) strategy within the EMR. METHODS A focus group of our hospital's transfusion committee consisting of transfusion medicine specialists, pathologists, residents, nurses, hemapheresis specialists, and information technologists was constituted and charged with the project. The group met periodically to implement e-charting TAMS workflow and produced electronic documents within the EMR (Cerner Millenium) for various service line functions. RESULTS The interdisciplinary working group developed and implemented electronic versions of various paper-based clinical documentation used by these services. All electronic notes collectively gather and reside within a unique Transfusion Medicine Folder tab in the EMR, available to staff with access to patient charts. E-charting eliminated illegible handwritten notes, resulted in more consistent clinical documentation among staff, and provided greater realered. However, minor updates and corrections to documents as well as select work re-designs were required for optimal use of e-charting-time review/access of hemotherapy practices. No major impediments to workflow or inefficiencies have been encount by these services. CONCLUSION Documentation of pathology subspecialty activities such as TAMS can be successfully incorporated into the EMR. E-charting by staff enhances communication and helps promote standardized documentation of patient care within and across service lines. Well-constructed electronic documents in the EMR may also enhance data mining, quality improvement, and biovigilance monitoring activities.
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Affiliation(s)
- Rebecca Levy
- Department of Pathology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Liron Pantanowitz
- Department of Pathology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Darlene Cloutier
- Department of Pathology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Jean Provencher
- Department of Pathology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Joan McGirr
- Department of Pathology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Jennifer Stebbins
- Department of Nursing, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Suzanne Cronin
- Department of Information Services, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Josh Wherry
- Department of Information Services, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Joseph Fenton
- Department of Information Services, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Eileen Donelan
- Department of Pathology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Vandita Johari
- Department of Pathology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Chester Andrzejewski
- Department of Pathology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
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Aase K, Høyland S, Olsen E, Wiig S, Nilsen ST. Patient safety challenges in a case study hospital--of relevance for transfusion processes? Transfus Apher Sci 2009; 39:167-72. [PMID: 18762458 DOI: 10.1016/j.transci.2008.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The paper reports results from a research project with the objective of studying patient safety, and relates the finding to safety issues within transfusion medicine. The background is an increased focus on undesired events related to diagnosis, medication, and patient treatment in general in the healthcare sector. The study is designed as a case study within a regional Norwegian hospital conducting specialised health care services. The study includes multiple methods such as interviews, document analysis, analysis of error reports, and a questionnaire survey. Results show that the challenges for improved patient safety, based on employees' perceptions, are hospital management support, reporting of accidents/incidents, and collaboration across hospital units. Several of these generic safety challenges are also found to be of relevance for a hospital's transfusion service. Positive patient safety factors are identified as teamwork within hospital units, a non-punitive response to errors, and unit manager's actions promoting safety.
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Affiliation(s)
- Karina Aase
- University of Stavanger, Faculty of Social Sciences, N-4036 Stavanger, Norway.
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Designing property specifications to improve the safety of the blood transfusion process. Transfus Med Rev 2008; 22:291-9. [PMID: 18848156 DOI: 10.1016/j.tmrv.2008.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Computer scientists use a number of well-established techniques that have the potential to improve the safety of patient care processes. One is the formal definition of a process; the other is the formal definition of the properties of a process. Even highly regulated processes, such as laboratory specimen acquisition and transfusion therapy, use guidelines that may be vague, misunderstood, and hence erratically implemented. Examining processes in a systematic way has led us to appreciate the potential variability in routine health care practice and the impact of this variability on patient safety in the clinical setting. The purpose of this article is to discuss the use of innovative computer science techniques as a means of formally defining and specifying certain desirable goals of common, high-risk, patient care processes. Our focus is on describing the specification of process properties, that is, the high-level goals of a process that ultimately dictate why a process should be performed in a given manner.
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Wiltbank TB, Giordano GF, Kamel H, Tomasulo P, Custer B. Faint and prefaint reactions in whole-blood donors: an analysis of predonation measurements and their predictive value. Transfusion 2008; 48:1799-808. [PMID: 18482188 DOI: 10.1111/j.1537-2995.2008.01745.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Thomas B Wiltbank
- United Blood Services, and Blood Systems, Scottsdale, Arizona; and Blood Systems Research Institute, San Francisco, California, USA.
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15
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Christov S, Chen B, Avrunin GS, Clarke LA, Osterweil LJ, Brown D, Cassells L, Mertens W. Rigorously Defining and Analyzing Medical Processes: An Experience Report. MODELS IN SOFTWARE ENGINEERING 2008. [DOI: 10.1007/978-3-540-69073-3_14] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Wittmann G, Frank J, Schramm W, Spannagl M. Automation and Data Processing with the Immucor Galileo® System in a University Blood Bank. Transfus Med Hemother 2007. [DOI: 10.1159/000107936] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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