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The NBTC indication codes were recently reviewed against current evidence and republished [https://nationalbloodtransfusion.co.uk/sites/default/files/documents/2024-10/NBTC-indication-codes-V3-2024.pdf].
The red cell codes R1-R6 have refreshed descriptions but remain broadly the same. The main change is the addition of the R7 code which was introduced to highlight the appropriate management of patients with severe chronic anaemia. It was clear from SHOT data that more needed to be done to help protect this vulnerable patient group from TACO.
Therefore, SHOT have produced a new TACO anaemia management resource, which comprises a decision flow-chart and explanatory text. This can be accessed by clicking on the image below, or found in the TACO Cumulative Data page.
What is this document about?
This good practice guidance document is based on existing UK guidance highlighting the importance of correctly understanding the reason for an ‘indeterminate’ blood group, resolving the blood group where possible and making the correct decisions for patient safety. This includes illustrative example cases based on previous reports to SHOT related to this issue.
Who is this for?
This guidance document is particularly aimed at hospital transfusion laboratory managers; transfusion IT (Laboratory Information Management System/LIMS and Electronic Patient Records/LIMS) providers; haematology medical staff and transfusion practitioners.
Why is this document needed?
Indeterminate ABO group on initial testing can lead to delays in transfusion and incorrect decisions in component selection. A UK NEQAS exercise and survey have highlighted gaps in practices and staff knowledge. This guidance document has been drafted to address issues identified. Policies, procedures and processes must consider the impact of communication, leadership, safety culture, human factors and ergonomics on safe decision-making.
How this has been developed?
Following a UK NEQAS Blood Transfusion Laboratory Practice (BTLP) exercise in 2023, this guidance document has been developed as a collaborative initiative by Serious Hazards of Transfusion (SHOT), United Kingdom Transfusion Laboratory Collaborative (UKTLC) and United Kingdom National External Quality Assessment Service (UK NEQAS).
Click here to access document: Good Practice Guidance for managing indeterminate ABO blood groups and support safe decisions final Dec2024
Click on link to access the infographic of the UK NEQAS and SHOT 2023 infographic – Uninterpretable ABO: blood group, group allocation and component issuing : UKNEQAS and SHOT Summary – infographic FINAL
Click on link to access the UK NEQAS and SHOT 2023 Uninterpretable ABO – blood grouping, group allocation and component issuing :UK NEQAS and SHOT Report – Uninterpretable ABO – blood grouping, group allocation
Why is this document needed?
There is a continuing trend in preventable transfusion errors reported to SHOT leading to patient harm including deaths. Common contributory factors identified include issues with staffing, training, safety culture and automation/IT.
What does it contain?
A driver diagram is a simple, visual tool used to conceptualise issues and determine the system components which will then create a pathway to get to the goal. This tool helps support staff to systematically plan and structure improvement projects.
How do I use it?
Drivers are the factors/areas that you need to change to see improvement. Change ideas are the tactical changes to processes and things that staff could do differently which will impact on the drivers recognised.
Use the driver diagram to identify potential tactical change ideas to enhance transfusion safety in your organisation. There is both a vertical and horizontal version for use.
This document has been created to support the implementation of safe IT systems within hospitals and transfusion laboratories
Why is this document needed?
Feedback from the SCRIPT user survey in 2020/21 suggested that transfusion services would appreciate more guidance on the functionality of transfusion IT. Actions for SCRIPT included reinforcing recommendations that electronic transfusion systems should be implemented, and to provide documentation on transfusion IT.
What does it contain?
This document has been created to support the implementation of safe IT systems within hospitals and transfusion laboratories. It details how properly developed and configured IT systems can be used in
collaboration with staff skills and knowledge to improve patient safety.
How do I use it?
It is arranged in two sections, firstly by Ten steps in the transfusion pathway and secondly by IT system. Each section contains identical information, however, is arranged differently for ease of use. Please use the index page for each section to navigate the document. Click here or on the image below to access the document.
Why is this document needed?
To outline the measures in place in the UK to minimise risk of transfusion-transmitted infections (TTI)
What does it contain?
Illustrative diagram of the transfusion process from donor selection, arm cleaning, diversion of initial donation, microbiological screening tests, optimal storage and transport, quality control processes and safe management of any suspected TTI cases.
How do I use it?
This image can be utilised as a training and educational tool to explain the measures in place to minimise TTI in the UK blood supply.
A DOI, or Digital Object Identifier, is a string of numbers, letters and symbols used to uniquely identify an article or document, and to provide it with a permanent web address. These DOIs will help readers easily locate the Annual SHOT Reports when cited. While a web address (URL) might change, the DOI will never change.
To assist in the investigation of wrong blood in tube (WBIT) events, SHOT have developed a WBIT investigation template. This form includes sections to help identify barriers and human factors (individual task related, equipment, team related, organisational, etc) that may contribute to WBITs. Using this template may help determine causal and contributory factors and improve patient safety by identifying gaps in knowledge and practice.
This document aims to answer questions regarding the recording, reporting and investigation of transfusion related adverse incidents in England following the introduction of PSIRF.
The following template has been developed to assist hospital laboratories in investigation where cord D-types are discrepant with D-type predicted by cffDNA screening.
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