In our first article about Transfusion Medicine (TM) safety we introduced the Transfusion Error Surveillance System, or “TESS,” a national initiative led by the Public Health Agency of Canada (PHAC), and we described Island Health’s significant contribution to this project on behalf of British Columbia. BC Patient Safety and Learning System (BC PSLS), through cooperation between our Central Office and Island Health Transfusion Medicine staff, has been modified to meet the national TESS reporting and coding standards.
Here, in Part 2, we follow-up with a key member of the Island Health TESS team, Kathy Paton, TESS Technical Resource Technologist, to learn more about the status of TESS and what she found from analysis of provincial event data. We also share our thoughts on why TESS is an important means to improving transfusion safety for all Canadians.
What’s happening with TESS in BC?
Island Health has been leading the way for TESS in BC for nearly a decade.
As a sentinel organization for the collection of transfusion data in Canada, Island Health has 15 acute care sites collecting TESS data, with 5 providing transfusion event data to PHAC.
The BC Provincial Blood Coordinating Office (PBCO) has been a strong supporter of TESS since it first launched in BC in 2006. In 2013, PBCO asked the Island Health TESS team to present their work to the other BC health authorities. This triggered a lot of excitement about the potential of TESS to standardize transfusion event reporting across BC, but a significant stumbling block prevented further expansion of TESS: a lack of resources with the right skills to “own” TESS in each of the health authorities.
BC PSLS wanted to help!
In 2014, BC PSLS Central Office extended its quality assurance activity to include a review of provincial blood transfusion-related event data in the BC PSLs database, under the leadership of Dr. Brian Berry and the Island Health TESS team.
From January to March 2015, Kathy has been applying TESS coding to all transfusion events reported in the province in 2014. With support from Derek Miller, Information Consultant (Island Health TESS team), their preliminary review of the data shows some interesting findings in the way transfusion events are reported across the province.
Taking a peek at provincial TESS data
“What we discovered is that there’s not only a difference in ‘how’ health authorities report transfusion events but also ‘what’ we report,” Kathy says.
“At Island Health we consider a transfusion error an actual event only if it has a direct consequence for the patient. For example, an actual event would be any error or event that resulted in an adverse transfusion reaction, a delay in transfusion, an incorrect dose being administered, a delay or cancellation of a medical procedure, product being transfused unnecessarily, or lost traceability of a blood product. Otherwise, we consider the event a Near Miss. The other health authorities don’t necessarily look at it that way, so it was a bit tricky to apply our TESS coding to their data.”
Let’s consider a mislabelled lab specimen, where the wrong label was applied to the tube after blood was drawn from a patient to match them to the right type of blood before transfusion.
At Island Health, this situation would be reported as a Near Miss because the error was caught before the patient received the blood transfusion and harm was prevented.
For the other health authorities, however, a mislabelled lab specimen is typically reported as a Patient Safety Event that actually occurred and caused harm to the patient because the sample would need to be recollected, meaning the patient would need at least one more needle poke.
Kathy explains, “Our goal in transfusion medicine is to capture all the errors as early in the transfusion medicine process as possible. We want to capture them before any product is transfused to a patient, and ideally, before the product leaves the lab. So we prefer to get the sample right, even if that means collecting the sample again, rather than possibly having the wrong sample. I didn’t want to change how other health authorities were reporting transfusion events but, at the same time, we want to bring the entire province on board with TESS.”
“We want to identify broader system level quality gaps.”
What’s next for TESS?
According to the Island Health TESS team, PHAC is very pleased with how far we’ve come with TESS in BC. In fact, they’re hopeful TESS will roll out to the rest of the province. Expansion of TESS to all BC health authorities will promote consistent reporting and analysis of transfusion errors and give us a more comprehensive picture of transfusion safety across BC. Province-wide use of TESS will also enable greater collaborative learning among all transfusion services in BC, improving quality of care and patient safety across the province, and the rest of Canada.
Stay tuned for further updates from the Island Health TESS team!
Did you know there’s a specialty form for “blood” events?
The Blood Transfusion or Blood Product specialty report form is available on the BC PSLS landing page to reporters in all health authorities. The form is helping to streamline data collection and improve data quality of transfusion events from across BC.
Over 10,000 reports about blood-related events have been submitted to the provincial BC PSLS database since Go Live of the form in February 2014.