The lens of PBM on World Patient Safety Day 2024

Tuesday 17 September was World Patient Safety Day, with the theme ‘Improving diagnosis for patient safety’, in recognition of the critical importance of correct and timely diagnoses. 

With the slogan ‘Get it right, make it safe’, the World Health Organization (WHO) calls for concerted efforts to reduce diagnostic errors. A diagnosis identifies a patient’s health problem and is a key to accessing the care and treatment they need.

Patient blood management (PBM) initiatives have helped ensure that the cause of anaemia is assessed, the underlying diagnosis and contributing factors determined, and specific therapy given where available. For example, in iron deficiency anaemia, this includes making sure investigation and management of the underlying cause/s (such as bleeding from serious GI pathology), and providing timely iron therapy in parallel, which can prevent unnecessary transfusion. Here are a couple key of resources for health professionals: 

• The Iron Deficiency Clinical Update 2022 from the Gastroenterological Society of Australia for General Practitioners and Physicians covers basic iron physiology, causes of iron deficiency, risk groups, symptoms, prognosis, management and prevention of the condition.   
• British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults (bmj.com) 2021 summarises contemporary evidence on the diagnosis and management of IDA in adults. 

Patient identification errors can contribute to misdiagnosis, patient harm and delays in care. Transfusion practice improvement initiatives both in Australia and internationally have developed many tools and resources to improve the safety of the transfusion process, including championing positive patient identification processes. ‘Wrong blood in tube errors’ (WBIT) can lead to the wrong diagnosis and treatment including transfusion of ABO-incompatible blood, and puts more than one patient at risk. 

The UK Serious Hazards of Transfusion (SHOT) program has been at the heart of creating an international culture of vigilance and continuous learning, collecting and analysing information on transfusion-related adverse events since 1996 and producing annual recommendations and contributing to continuous learning. SHOT has developed many valuable tools and resources to address risks and problems identified to improve patient safety. 

The most recent SHOT report (2023) highlighted a continuing trend in preventable transfusion errors leading to patient harm, including deaths. Common contributory factors identified included issues with staffing, training, safety culture and automation/IT. 

Here are few featured resources from the recently released 2023 annual report to enhance transfusion safety: 

• Driver Diagram to help identify tactical change ideas to enhance transfusion safety - a simple, visual tool used to conceptualise issues and determine the system components which will then create a pathway to get to the goal. It helps support systematic planning and structure improvement projects.
• The TACO Incident Investigation Guidance Tool, developed to support local investigations following reports of transfusion-associated circulatory overload (TACO) and identify areas for improvement, in conjunction with local policies.

You can find more featured resources from the 2023 SHOT report here: 

Current Resources - Serious Hazards of Transfusion (shotuk.org)