Original article

Ahead-of-Print

Development and evaluation of trigger tools to identify pediatric blood management errors

Authors

Key words: Patient Blood Management, medical errors, trigger tools, quality improvement
Publication Date: 2024-03-27

Abstract

Background - Pediatric patient blood management (PBM) programs require continuous surveillance of errors and near misses. However, most PBM programs rely on passive surveillance methods. Our objective was to develop and evaluate a set of automated trigger tools for active surveillance of pediatric PBM errors.

Materials and methods - We used the Rand-UCLA method with an expert panel of pediatric transfusion medicine specialists to identify and prioritize candidate trigger tools for all transfused blood products. We then iteratively developed automated queries of electronic health record (EHR) data for the highest priority triggers. Two physicians manually reviewed a subset of cases meeting trigger tool criteria and estimated each trigger tool’s positive predictive value (PPV). We then estimated the rate of PBM errors, whether they reached the patient, and adverse events for each trigger tool across four years in a single pediatric health system.

Results - We identified 28 potential triggers for pediatric PBM errors and developed 5 automated trigger tools (positive patient identification, missing irradiation, unwashed products despite prior anaphylaxis, transfusion lasting >4 hours, over-transfusion by volume). The PPV for ordering errors ranged from 38-100%. The most frequently detected near miss event reaching patients was first transfusions without positive patient identification (estimate 303, 95% CI: 288-318 per year). The only adverse events detected were from over-transfusions by volume, including 4 adverse events detected on manual review that had not been reported in passive surveillance systems.

Discussion - It is feasible to automatically detect pediatric PBM errors using existing data captured in the EHR that enable active surveillance systems. Over-transfusions may be one of the most frequent causes of harm in the pediatric environment.

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Authors

Swaminathan Kandaswamy - 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

Cassandra D. Josephson - Departments of Oncology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America; Cancer and Blood Disorders Institute, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, United States of America

Margo R. 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

Jennifer Jones - Cancer and Blood Disorders Institute, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, United States of America

Patricia Zerra - 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

Ruchika Goel - Simmons Cancer Institute at Southern Illinois University School of Medicine and ImpactLife Blood Centers, Springfield, IL, United States of America

Jennifer Andrews - Division of Transfusion Medicine, Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States of America; Division of Hematology and Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States of America

Jeanne E. Hendrickson - Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States of America

Lani Lierberman - Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada

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

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