Transfusions of blood and blood products are an important part of healthcare. When adverse events related to transfusions occur, the impact on patients can be considerable with negative outcomes such as ABO blood group incompatibility, delays in care, inappropriate transfusions, or product wastage.

Derek Miller and Kathy Paton of the Island Health TESS team

To learn more about how to prevent transfusion events and improve patient safety, the Public Health Agency of Canada (PHAC) launched the Transfusion Error Surveillance System (TESS) pilot project in 2005.  Their goals were to collect comprehensive data about adverse events involving transfusions, provide benchmarking data to Canadian hospitals, and support continuous improvement in transfusion safety.

Joining the TESS pilot were Victoria General and Royal Jubilee Hospitals at Island Health (VIHA), which were invited to participate in this national initiative on behalf of BC.  A TESS team was formed, under the leadership of Dr. Brian Berry, to manage the project on behalf of Island Health and their involvement has been ongoing ever since.

When BC PSLS rolled out across Island Health in 2011, its implementation presented some unforeseen challenges for the TESS team, particularly as it changed the way transfusion events were reported and what was reported.  They were unsure how their work would be impacted by BC PSLS.  But perhaps more importantly, they were uncertain how BC’s contribution to this national patient safety initiative would be affected.

“Back then, we didn’t know how, or even if, the two systems could work together,” says Kathy Paton, Technical Resource Technologist for the Island Health TESS team.  “BC PSLS became the primary reporting and management tool for all types of patient safety events, including transfusion events, and we didn’t know how this would affect our future work and years’ worth of data collection in TESS.”

Fortunately, Kathy and her team reached out to BC PSLS Central Office to discuss and explore potential solutions.  It took some time, but after several brainstorming sessions, collaborative meetings, and database iterations, a solution was found…BC PSLS was set up to collect TESS data and TESS data could indeed be retrieved from BC PSLS!

Much has happened over the past few months and Island Health has since become the sentinel site for the collection of transfusion data in Canada, with 15 acute sites providing transfusion event data to PHAC using data first reported into BC PSLS.

Today, with support from the BC Provincial Blood Coordinating Office (PBCO), the Island Health TESS team is focused on extracting the data from BC PSLS and developing reports to share with transfusion safety groups in British Columbia, across Canada, and eventually internationally,

TESS reports are distributed quarterly to Transfusion Medicine stakeholders in VIHA and presented annually to PHAC.

Derek Miller, Information Consultant, joined the Island Health TESS team to lead this work and develop a suite of advanced, interactive reports.  “Our goal is to use the business intelligence tools offered through BC PSLS to pull transfusion data out of the system and apply denominator data for a more complete picture,” he says. “It’s really exciting to see this work coming together.”

Derek says the reports are customizable, allowing users to select specific parameters such as date range or location, and can be automatically distributed to recipients with appropriate permissions. Report indicators highlight serious transfusion events so nothing significant gets missed by the report viewers.

Stage of Discovery graph shows that the majority of Transfusion events are discovered before reaching the patient.

Describing the BC PSLS analytics tool, Derek says, “The beauty of SAP’s Business Intelligence web-based application is that I can work on the reports from any computer in VIHA.  That way I can help people find the information they need without having to install any special software.  The application is capable of producing sophisticated reports, which are being very well-received by our colleagues in VIHA and other national agencies.”

Graph demonstrates error rates for specific transfusion safety events in BC PSLS combined with denominator data from VIHA.

All in all, this initiative has resulted in an extraordinary partnership between the Island Health TESS team and BC PSLS Central Office.  Certainly, this collaborative effort will enhance our learning about transfusion events and lead to improvements in transfusion safety in Canadian healthcare settings.

Additional resources:

• BC Provincial Blood Coordinating Office (PBCO)
• Transfusion Medicine Advisory Group (TMAG)
• Transfusion Error Surveillance System – Pilot Project Report 2005-2007

Kathy Paton is Technical Resource Technologist and Derek Miller is Information Consultant with TESS at Island Health. For more information about this initiative, please contact them by email Katherine.Paton@viha.ca or Derek.Miller@viha.ca