Organisational change - Implementation of the two-sample rule for ABO/D grouping prior to the issue of RBC

Abstract

ABO grouping is an important serological test performed on pre-transfusion samples. Unless secure electronic patient identification systems are in place, a second sample should be requested for confirmation of the ABO group. Burton Hospitals Blood Bank does not utilise a patient identification system. The 2 Sample Rule was introduced following a near-miss event of a Wrong Blood in Tube sample identified by a nurse providing a sample. Aim: The aim of this study was to evaluate the effectiveness of the introduction of a two-sample rule for transfusion of red blood cells (RBC) in a 450-bedded acute hospital. The purpose of this was to reduce the risk of ABO incompatible transfusion. Methods: A review of the Trusts practices was undertaken prior to implementing the 2 Sample Rule. A small-scale local audit was undertaken for three months post implementation to evaluate effectiveness of implementation. An organisational change management implementation approach was utilised. A systematic diagnosis of the current situation identified that current practice did not adhere to national pre-transfusion compatibility testing recommendations, and could potentially result in a transfusion of an incorrect blood product (Never Event). Approximately 80% of patients had a historical ABO group identified. Ability to identify specific patient groups who did not have this allowed for targeted implementation steps. Managing the change required involvement from the Hospital Transfusion Team, Hospital Transfusion Group and the Trusts Governance Groups to ensure support from the Directors and the utilisation of Governance structures to manage risk. A launch date for the 1st of August 2014 was agreed; chosen as it coincided with the Doctors change over period. A Patient Safety Week was held which included information stands, visits to clinical areas, distribution of information flyers and attending team meetings. Specific training was delivered directly to key areas where change in practice was required. Results: During the three month period 320 patients required transfusion of RBC's. This equated to 750 units of blood. 29 patients received 92 units without a 2nd sample due to emergency transfusion (9% of patients, or 12.2% of units transfused). Of these 92 units issued, 56 were issued to group O patients. 36 units were issued to patients with other blood groups (15 patients or 4.8% of red blood cells issued). During the implementation phase, use of O-Neg blood increased by 0.5%, and use of OPos increased by 11.7%. On-going monitoring shows this is reducing. Conclusion: Implementation of the 2 Sample Rule required planning and assessment. Initially there was minimal resistance, but this was soon overcome when people understood the benefits and the numbers of patients affected. The ability to understand where to target change was hugely beneficial. Clear guidance is needed to define '2 samples'. The audit showed that there was an improvement in the understanding of the 2 Sample Rule, and that initial concerns regarding an increased usage in O-Neg/O-Pos blood was justified, but not to the extent expected.