A Proactive Risk Assessment of Electronic Blood Product Ordering

Transfusion of blood components is a complex multidisciplinary process from provider order, to blood bank processing, to administration. Errors at any of these points can result in great harm to the patient. Given the complexity and high-risk process of blood ordering, one of our 2016 quality and patient safety (QPS) goals was to conduct a proactive risk assessment (PRA) for blood product ordering using failure modes and effects analysis (FMEA) methodology. The scope for this project included electronic routine order of all blood products through the point of pickup for all locations, excluding the operating rooms, where the electronic order system is not used. The steps prior to the order (type and screen [T&S] specimen collection and testing) and the steps following product pickup (transfusion of the product) were outside of the scope of this project. The FMEA tool was used to identify possible failure modes to reduce these risks. Initially, the clinical systems engineers (CSEs) from the QPS department conducted interviews and observations of the process. Subsequently, two interdisciplinary teams (East Campus and West Campus), comprising key stakeholders from each step of the electronic blood ordering process, were formed and led by the CSEs. The PRA consisted of creating a process map, identifying potential failure modes for each sub-step, assigning a risk score to each potential failure mode, and identifying the potential failure effects and causes. Failure modes were scored for three indicators: severity (S), likelihood of occurrence (O), and probability of detection (D). A risk priority number (RPN) was calculated by multiplying S by O by D. For those failure modes with RPN ≥81, mitigation strategies were developed by the interdisciplinary teams. The East Campus identified 54 failure modes (30 with RPN≥81), and the West Campus identified 103 failure modes (34 with RPN≥81). Potential causes of these failures revealed a wide range, including human error (eg, incorrect patient selected), interdisciplinary communication (eg, inaccurate identification of contact information), IT/equipment (eg, multiple IT systems interfaces), and process issues (eg, lack of transfusion history). Risk mitigation strategies include an enhanced order entry set with logic-based alerts and a streamlined pickup process. In addition, a nursing task list is being developed to facilitate pre-transfusion processes. Finally, a transfusion dashboard is being designed to improve the access of ordering providers to relevant information (eg, transfusion history, transfusion reactions, relevant labs, and T&S status). FMEA is useful for proactively addressing risks for a highly complex process, such as blood product ordering, to identify issues and improve the process. The ultimate goal of this FMEA is to improve quality and patient safety, by preventing transfusion delays and erroneous blood product administration.