Enhancing blood transfusion safety

Receiving an incorrect blood transfusion can have life-threatening consequences. Traditionally, the compatibility between patients and blood products was assessed manually. In our pursuit of minimizing the likelihood of errors and near-misses, we conceptualized and created a digital blood-type-compatibility control system.

Orgamnization
Hôpital du Valais

Year
2018

Role & team
Leading designer, working with POs, software developers and various hospital stakeholders

TL;DR

Challenge

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Approach

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Result

The blood transfusion process involves multiple identity checks, traditionally requiring two nurses to ensure patient safety. Additionally, space constraints at the patient's bedside and the need to maneuver two trolleys – one with equipment and one with a laptop for documentation – add to the complexity.

Our mobile app leverages barcode scanning to streamline identity checks, enabling a single nurse to quickly verify patient and blood product details, enhancing both speed and patient safety. The app also eliminates the need for a laptop trolley, reducing clutter and improving maneuverability.

The mobile app's design seamlessly aligns with the desktop application for blood transfusions, ensuring a consistent user experience.

Understanding nurses’ workflows

As part of this project, I had the chance to immerse myself in the daily routines of nurses for a week, I observed their tasks and engaged in insightful coffee break conversations. Some of the challenges I have observed:

  • Digital and non-digital task switching: Nurses often switch between digital and non-digital tasks, sometimes resorting to temporary paper notes due to time constraints or limited computer availability.
  • Inadequate hardware: In patient rooms, nurses use laptops placed on trolleys. However, these trolleys are too small to also carry essential medical supplies. For tasks like blood transfusions, this forces nurses to juggle multiple trolleys, complicating bedside care.
  • Task- instead of patient-based workflows: Workdays are organized by tasks rather than patients, resulting in nurses completing one task (e.g.: handing out medication) for all patients before moving to the next task.
  • Workarounds for technology gaps: To address the limitations of existing technology, nurses often resort to printing patient lists and taking handwritten notes throughout the day. These improvised solutions add to their workload.

The journey of a blood product: From lab to bedside

The blood transfusion process is tightly regulated, requiring strict adherence to protocols. We thoroughly examined the journey of a blood product from lab to patient to identify inefficiencies and safety risks.

  • A time-consuming compatibility check: Confirming patient-blood product compatibility at the bedside is a lengthy process that requires the involvement of two nurses.
  • Paper dependency increases risk: Blood products are tracked using a paper card attached to the bag. Errors made in the lab when attaching the card can go undetected, increasing the risk of transfusion mistakes.
  • Inadequate reaction documentation:  Transfusion reactions and near-misses are often poorly documented due to the complexity of required forms, hindering effective quality control.

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

Connecting the right systems to allow information exchange

To enhance the efficacy and safety of blood transfusions, a series of improvements were implemented. A new API was developed to integrate the laboratory software with the electronic health record (EHR), enabling seamless data exchange. In addition, the transfusion documentation form within the EHR was redesigned to improve usability. Furthermore, a specialized app was created for nurses, enhancing the efficiency of transfusion-related tasks at the bedside.

  • Consistency in user interface: The redesigned transfusion documentation form within the EHR now features a standardized layout, including a header with primary actions and a sidebar displaying critical patient information. This ensures a consistent, intuitive, and user-friendly interface across the system.
  • Efficiency through barcode scanning: The new app, equipped with a barcode scanner, allows nurses to quickly scan both the blood product and patient bracelet. This process eliminates the need for a second person to verify the match, enhancing both speed and accuracy.
  • Control at the bedside: The newly developed API facilitates real-time cross-referencing of the patient's bracelet barcode and the blood product label with the laboratory database, just prior to transfusion. This eliminates reliance on paper-based label verification, improving accuracy and reducing the risk of errors.
  • Streamlined transfusion reaction documentation: Transfusion reactions and near-miss events can now be documented directly within the EHR or through the specialized app. Nurses no longer need to use complex third-party forms, simplifying the process and reducing the potential for documentation errors.

The transfusion documentation form of the EHR highlights possible past adverse events.

The new application allows the nurse to easily send a report about the course of the transfusion.

Thanks to the countdown the blood transfusion must be started directly after the compatibility check.