Improving blood transfusion safety

Receiving a wrong blood transfusion can be life-threatening. Until recently the compatibility between a patient and a blood product had been controlled only manually. To reduce the probability of mistakes happening we designed and developed an additional digital compatibility control.

Responsibilities
Research
User Experience Design
UI Design
Usability Testing

Year
2018

Field research

Following the journey of a blood product: from lab to patient

Designing hospital software is not only about the UI. It is crucial to understand all aspects of the workflows and answer questions such as: Are there always enough computers available? Is the connection good enough in the patient room? What other touchpoints does the user interact with while using the software?

Desk research

Understanding regulations

The process of blood transfusion is highly regulated and certain rules must be followed. To understand if there were gaps between best practices and the reality at the hospital we interviewed experts and conducted extensive desk research.

Analysis

Uncovering pain points

I consolidated findings from the desk research and interviews with users and experts in a user journey. The main pain points were:

The process is very time-consuming – With the current solution, two nurses are needed to control the compatibility between patient and blood product. There is no digital support, even though the required information exists in the system.

Use of paper increases the likelihood of errors – Once the blood product leaves the laboratory, the only information about which patient the product is intended for is a piece of paper attached to the blood bag. If an error occurs in the lab when attaching the card, there is a high risk that the error is not discovered before the transfusion.

Transfusion reactions are not documented sufficiently – The documentation of transfusion reactions often gets neglected because the required form is hard to find. This makes it hard to establish quality control.

The user journey map shows areas of high risks for patient safety and inefficient processes.

Technology

Connecting the right systems to allow information exchange

The laboratory technicians work with different software than the nurses. A card with the patient’s name attached to the blood product was the only information exchange between the two systems.

However, for the new application, a web service was created that would allow the lab software to send information directly to the electronic health record (EHR) used by the nurses.

Furthermore, the new form would allow the nurses to scan a patient’s bracelet with a scanner attached to the computer, rather than having to input the patient ID manually.

The solution

From registration to control of the blood product

When the form is opened it directly displays the patients’ blood type, past transfusions and reactions and a bold button invites the user to add a new blood transfusion.

Consistent user interface – The form includes a header with main actions as well as a sidebar with crucial patient information.

A new one-person workflow thanks to a bar code scanner – A nurse can now scan the blood product and patient bracelet which triggers a control in the laboratory database. This replaces the control by a second person.

Control at the point of transfusion – The bar code of the patient bracelet and the blood product are compared to the laboratory database directly before transfusion. This means nurses no longer have to rely solely on a piece of paper attached to the blood product.

Simplified documentation of transfusion reaction – The new interface includes all necessary links to make it easier to properly document transfusion reactions.

The starting page shows past transfusions and adverse events.
The nurse is guided through a step by step process to control the compatibility between the patient and the blood product and register the transfusion.
The new application allows the nurse to easily send a report about the course of the transfusion.