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Thread: One persons SABRE is another ones Normal practice

  1. #1
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    One persons SABRE is another ones Normal practice

    Hi All

    I was performing some LIMS validation and we were checking the setup for a warning about giving random adult units to a baby. As the guidance says we should order in specific units for these patients if time allows. When testing there was no warning so as we share the LIMS with other sites I asked what they thought. One site did not want a warning because they only select the most appropriate units off their shelf. There is no consideration about the donors donation history. When asked why, it was because the guidelines say should not must.

    I try to conform to all recommendations in guidelines. So in my SOP the procedure is to order large volume units (time permitting) from NHSBT. If a member of staff did not do this and selected most appropriate unit of the shelf and issued it when there was time to order it from NHSBT the process has not been followed and I need to complete a SABRE and investigate. But the BMS in my lab are doing what the other Trusts do, hence the title of this thread.

    Is there a case for not reporting such incidents if it is not a must in the guidelines?
    The argument for reporting is that the process was not followed so it could go wrong elsewhere. However all this will do is encourage me to stick to the minimum "Must" recommendations from the guidelines and not pursue best practice as no one like SABRE reports.

    What are others thoughts on this?

  2. #2
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    Hi TW-B,
    I like the title of your question, and yes it probably is- but if you are on the road to quality improvement that's what it all about- making our processes better/safer for both our staff and patients.

    Please can you clarify some points. Blood specification requirements for Intra- Uterine Transfusions (IUT), top-up transfusions, large volume exchanges or to cover major bleeding in neonates/ babies can differ depending on the situation/ urgency and presence of any maternal antibodies. In some situations concessions can apply.

    If you can please also expand on there being no consideration about the donors donation history by some sites, with an example that would help too.

    The situation you describe in that your SOP states ordering large volume units if there is time from the NHSBT, and this was not followed- would probably be SABRE reportable, but this again depends on the situation/ reason for transfusion/ age of baby. We need to look at the risks to the patient in terms of best treatment and care, and giving sub-optimal units in a non-urgent situation isn't right regardless of what other sites are doing. Has anyone considered the impact of high potassium levels in a large unit of stock/ older blood given to a neonate- could result in cardiac failure?

    SABRE reporting should be regarded as a quality improvement activity- you are identifying things that aren't quite right and are trying to fix these- and everyone should be commended in doing this (apart from being a regulatory thing!).

    Be great to discuss further and perhaps others reading this post could assist?

    best wishes
    Last edited by Rashmi; 19th Mar 2019 at 10:26 PM.

  3. #3
    Bear with me, as it will be very difficult to address some of these points without risk of being misinterpreted!

    The BSQR exists to ensure quality and safety of the component and that it meets the requirements of the patient without risk of harm, and not specifically to ensure that guidelines are met. It is up to each BB to decide how to meet the guidelines, or to risk assess and justify why they might not meet the guidelines.

    Your entire QMS is made up of numerous parts to ensure compliance. For example the existence or non-existence of flags or warnings is not the be all and end all of ensuring the correct component is selected. If the process is robust enough to ensure the correct component is selected, that would be acceptable. However, often processes are not totally robust and flags and warnings are deemed to be necessary. Unfortunately it is not one-size-fits-all.

    When it comes to "error reporting" (I won't say "SABRE" reporting as that is another chapter entirely) it would depend on whether a process/SOP was deviated from.

    If your SOP states that "Patient requires X, you must supply X" then you supply X or it is an error
    If it states "Patient requires X, you must supply X unless X is not available, or cannot be supplied in time, then it is acceptable to supply Y" and Y is supplied that is not an error.

    When investigating the first situation, you may decide that is too rigid and an improvement can be made to change the process to the second example. If you are concerned that situation 2 is too flexible and open to misuse, then a robust deviation process that is used to manage the process of deviations from strict procedures is also acceptable.

    So, I think it is true that different blood banks might be doing different things to interpret guidelines and meet compliance, but whether something is an error or not depends on what the SOP says and how you deviate from it.
    Last edited by Chris Robbie; 20th Mar 2019 at 11:45 AM.

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