Abstract

Background - Children are at increased risk from transfusion-related medical errors. Clinical decision support (CDS) can enhance pediatric providers’ decision-making regarding transfusion practices including indications, volume, rate, and special processing instructions. Our objective was to use CDS in a pediatric health system to reduce:
1. blood product-related safety events from ordering errors;
2. special processing ordering errors for patients with T-cell dysfunction, sickle cell disease (SCD), or thalassemia;
3. transfusions administered faster than 5 mL/kg/h.
Materials and methods - In this single-center before and after quality improvement study, we evaluated how user-centered design of pediatric blood product orders influenced pediatric transfusion practices and outcomes. Safety events were identified through active and passive surveillance. Other clinically relevant outcomes were identified through electronic health record queries.
Results - Blood product-related safety events from ordering errors did not change significantly from the baseline period (6 events, 0.4 per month, from 1/1/2018-3/27/2019) to the intervention period (1 event, 0.1 per month, from 3/28/2019-12/31/2019; rate ratio: 0.27 [0.01-2.25]). Packed red blood cell (PRBC) and platelet orders for patients with T-cell dysfunction that did not specify irradiation decreased significantly from 488/12,359 (3.9%) to 204/6,711 (3.0%, risk ratio: 0.77 [0.66-0.90]). PRBC orders for patients with SCD or thalassemia that did not specify phenotypically similar units fell from 386/2,876 (13.4%) to 57/1,755 (3.2%, risk ratio: 0.24 [0.18-0.32]). Transfusions administered faster than 5 mL/kg/h decreased from 4,112/14,641 (28.1%) to 2,125/9,263 (22.9%, risk ratio: 0.82 [0.78-0.85]).
Discussion - User-centered design of CDS for pediatric blood product orders significantly reduced special processing ordering errors and inappropriate transfusion rates. Larger studies are needed to evaluate the impact on safety events.

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Authors

Evan W. Orenstein - Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America; Division of Hospital Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, United States of America

Margo Rollins - Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America; Aflac Cancer and Blood Disorders Program, Children’s Healthcare of Atlanta, Atlanta, GA, United States of America; Department of Pathology and Laboratory Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, United States of America

Jennifer Jones - Aflac Cancer and Blood Disorders Program, Children’s Healthcare of Atlanta, Atlanta, GA, United States of America

Swaminathan Kandaswamy - Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America

Jeanne Boudreaux - Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America; Aflac Cancer and Blood Disorders Program, Children’s Healthcare of Atlanta, Atlanta, GA, United States of America

Alexis B. Carter - Department of Pathology and Laboratory Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, United States of America

Cassandra D. Josephson - Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America; Aflac Cancer and Blood Disorders Program, Children’s Healthcare of Atlanta, Atlanta, GA, United States of America; Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States of America; Department of Pathology and Laboratory Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, United States of America

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