The Long Road to Haemonetics. March 2015 Nada Nsier Transfusion Safety Coordinator Kristin Yanitski and Molly Ortlieb Tech I Kathy Hamacher Tech III

Transcription

1 The Long Road to Haemonetics March 2015 Nada Nsier Transfusion Safety Coordinator Kristin Yanitski and Molly Ortlieb Tech I Kathy Hamacher Tech III 1

2 Who Collaboration between Laboratory Medicine, Kaye Edmonton, and Stollery Children s Hospital Laboratory: Tech I s Tech III SOP Writer Transfusion Safety Coordinator Manager LIS team 2

3 Where? 3A Adult Day Medicine and PICU contain HemoSafes 3D Medicine Clinic contains the Helmer Fridge (refrigerated products) Kiosks & Cabinet (room temperature products) 3

4 When? Year Action 2009 Equipment list developed for KEC 2011 TM Manager consulted for equipment selection Summer 2012 Equipment chosen/ Negotiations began March 2014 Equipment installed June 2014 Initial training for Haemonetics Group July 2014 Configuration and Validation began December 2014 Super-user/Frontline Staff Education Week of Feb 9 Go-Live 4

5 A quick glance Scope of Project Total Tech I time = 525 hours This excludes any time put in by LIS team, the manager, the Tech III, the Transfusion Safety Coordinator, and the SOP writer. 5

6 Background Information CPSA Standards - TM.11.2 Transfusion Identification TM (PS) Policies, processes and procedures are in place to ensure continuous and unequivocal identification of the recipient and blood component or blood product. PS Patient Safety non-compliance may have direct and/or immediate impact on patient safety 6

7 Blood Administration: Patient Identification Check Immediately before transfusion at the patient s bedside, 2 individuals must check: 1. ID band info (first and last name, ULI) vs. transfusion tag 2. BBIN vs. transfusion tag 3. Unit number and blood group on bag vs. transfusion tag Visual inspection of unit for clots, leaks DOE, JON BB O POSITIVE O POSITIVE C M PACKED CELLS 3 CXM Compatible 07Oct11 7

8 Background Information Blood stored on patient care units for emergent use (e.g. PICU, ER, OR) and/or distance (e.g. ADM, CFBD). One shelf for multiple patients. Increased chance of selecting the wrong unit and transfusing to the wrong patient. 8

9 Non-Conforming Event April unit of A Pos RBC was issued to Mickey Mouse. 1 unit of O Pos RBC was issued to Donald Duck. Both units stored in the fridge on the same shelf. Wrong unit was selected. Checks at Bedside were not completed. 9

10 Non-Conforming Event cont d Unit of A Pos RBC given to the O Pos patient. 10

11 Which led to All products were pulled from Patient Care Unit. Process changed to issuing patient specific bed-side cooler. 11

12 QAR Recommendation It is recommended that a new blood storage system and associated equipment be acquired and implemented by Stollery. Haemonetics HemoSafes were selected. 12

13 Why? Ensure that only units allocated/issued to a specific patient will be selected. Meet CPSA an additional check at time of retrieval of unit from fridge. Direct affect on blood bank, decrease cooler use. Transfusion at time of need (on-demand) 13

14 14

15 BloodTrack Modules BloodTrack Manager BloodTrack Enquiry BloodTrack Courier Information Management Transfusion Workflow BloodTrack Tx BloodTrack HemoSafe Crossmatched Inventory Transfusion Verification Just-in-Time Inventory 15

16 What does it do? BloodTrack Manager tracks blood units in the hospital; electronically capturing information about blood units whenever they move from one location to another. This creates a complete audit of the movements of blood units in real time, with no need to manually record transactions. 16

17 How does it work BloodTrack Manager runs on a PC in the Blood Bank and uses a handheld scanner to track the movement of blood unit in and out of the Blood Bank. 17

18 How does it work The BloodTrack Service (BTS) provides the foundation of the BloodTrack system. The BTS does all of the transaction processing on behalf of the BloodTrack Courier, BloodTrack Manager and BloodTrack Tx clients. 18

19 Benefits Monitors blood units outside of the blood bank. Provides detailed reports on blood units history, refrigerator inventories, and current locations of all blood units. Immediately warns if a blood unit has been out of a refrigerator for too long or when established rules for blood products have been violated. Monitors and warns if temperature levels are out of range, blood stock levels are low or if a BloodTrack station is offline. 19

20 Home Screen of BloodTrack 20

21 At the Hemosafe/Kiosk Manual Login 21

22 Putting In to the Fridge GOOD 22

23 Taking out of the Fridge 1 2 We DO NOT select a Transport Method when Taking Out

24 Taking out of the Fridge 24

25 Taking out of the Fridge

26 Vending Machine 26

27 Hemosafe 27

28 OUR JOURNEY 28

29 Validation Validation included: every group of red cells (plus irradiated) every vial size of every plasma protein product already allocated plus remote allocation of each product (including unmatched for alias with no patient information or testing) take out and return to fridge for each product error messages (exceeding transport times, answering 'no' at the visual inspection step, timing out at various points in the process. etc.) attempt to put one of every not allowed' product into each device 29

30 Hardware/Equipment Issues Delayed Go-Live PICU Hemosafe Needed servicing in August circuit breaker replaced in November Cabinet Kiosk Ongoing since September Motherboard replaced in early December Motherboard replaced again in January The whole kiosk was replaced end of January

31 Hardware/Equipment Issues Printer issues since September 2014 with both HemoSafes. Solved with cable replacements in January ADM HemoSafe A catastrophic domino of failures put ADM HemoSafe out of commission the first week of January (power board failure led to main communication board overheating and frying which led to the capacitor blowing). Kiosks at KEC Intermittent network problem that occasionally causes communication interruptions between the server and Kiosks. 31

32 Laboratory Information System Challenge There is NO communication between Sunquest and BloodTrack How do we get the 5 point identifier from Sunquest to BloodTrack? Solution Created a unidirectional information push via our tag printer. Re-designing our tag to have more information. 32

33 Five Point Identification 33

34 Red Blood Cells (RBC) vs Plasma Protein Products (PPP) Challenge System is designed for RBC No major issues. How to get the system to read and recognize PPP products? Solution 'PPP' was put in front of all PPP products, except albumin. *this lead us to another challenge* 34

35 Nuisance Alerts Challenge Due to the nature of the information capture (via the tag print), there was an alert every time a tag printed for an unconfigured product. Solution We had to configure all the commonly used products in the lab even if they were never going to be tracked by BloodTrack (e.g. platelets) 35

36 RT Products stored in Fridge Challenge Issue Fridge aka virtual holding area Solution Tricked it! Reconfigured RT products that they could be stored in a fridge. Question: Is this acceptable/safe/make you twitch? 36

37 CFBD Pseudo-Batch Challenge Volume of product being issued to one patient during a visit (e.g vials of Hizentra for home use). Solution Pseudo-batch 37

38 Other small but important details Challenge 1 BloodTrack looks for certain fields. If field is blank, it defaults to the next. Solution Haemonetics Software Fix 2 Field length too short or too long. Haemonetics Software Fix 3 BloodTrack-generated label for Remotely Allocated products. Trial and Error and meeting AABB Standards 4 Sunquest Upgrade happened Re-configure information flow 38

39 Ongoing Challenges Challenge 1 Reprinting Tags for products in BloodTrack 2 Where does Sunquest think the product is? 39

40 Future Perspectives Sunquest patch, bidirectional system, and BloodTrack Tx Other wards interested ER and OR New HemoSafes without moving component partnered with Helmer 40

41 Questions? 41