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.
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.
Pain points
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.
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.
Improvements
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.
