Nursing Standard Seven Bloods-2386281

Introduction

Good afternoon, my name is Atalia. I am here with Alana, Sharmane, and Suesan to present our review of the National Safety and Quality Health Service Standard 7, blood management, focusing on standard 7.07 reporting adverse blood management events.  

The National Safety and Quality Health Service (NSQHS) Standards were developed through the collaboration between the commission and the Australian Government, the private sector providers, clinical specialists, patients, and carers. The main goals of the NSQHS standards are safeguarding the population against unjust activity and enhancing the quality of health service delivery. Eight NSQHS standards give a statement consistent across Australia and New Zealand on the level of care expected of the consumers accessing the health care services (ANZSBT & RCN, 2011). As one of the major tools in our nursing practice, the blood management standard is setting the stage to enhance patient outcomes by identifying risks and deploying strategies that could maximise and save a patient’s blood, while keeping the received blood and products safe and appropriate. The blood and the blood products under control by this standard are fresh blood components, plasma derivatives, and recombinant products. The aim of standard 7.07 is that adverse transfusion events are reported in order to assist in identifying prior adverse reactions or transfusions as well as in motivating valuable opportunities. As healthcare providers, we are responsible for ensuring the proper management and avoidance of adverse blood management events.

By identifying Standard 7.07 as significant, the following relevant issues can be stated: reporting is an essential part of clinical practices that can ensure safer outcomes only due to the accuracy and timeliness of reporting. Reporting about adverse events can not only lead to quickly detecting patterns or risks related to the transfusions, but also helps to develop better protocols and instructions for staff members (Australian Red Cross Blood Service, 2015). It allows healthcare institutions to measure their performance and make changes to the practice in order to improve the safety of the patients. In the process, it gets a culture of responsibility and constant change. Thus, integrating this standard into the routine nursing practice is not routine but an essential step towards high quality patient-centred care.

Critique of evidence base

While we critiqued each reference found relating to our chosen focus individually, we have presented our findings as a combined group of evidence and have clearly defined the strengths, limitations, and gaps of the critiqued data. The strengths of our review include that the resources are provided by reliable guidelines such as the National Blood Clinical Advisory Council, a statutory agency, and the Australian and New Zealand Society of Blood Transfusion, governed by a group of seven elected council members. Also included in the reliable guidelines is the Australian Red Cross Lifeblood, which the National Council and the Royal Commission govern. We know these references are reliable as they are based on a strong foundation of evidence, developed and written by experts who have been transparent in their reported findings of Serious Transfusion Incident Reporting (STIR). Another strength that was found within the critiqued references is the clear and strong support of the standard in reporting adverse blood events and providing comprehensible recommendations for health services to follow (ANZSBT & RCN, 2011). This strength is reported in the articles to ensure patient safety, improve blood product quality, and enhance transfusion practices, a mutual finding. Overall, the critiqued evidence mostly contained recent updated guidelines and reports that have been remodelled to reflect best practice, based on current studies and knowledge.   

However, there were multiple limitations found within the critiqued references. The original references and data reported were not written in the last 5-10 years. Furthermore, the more recent updated reports were not referenced correctly, and the recommendations in the references regarding reporting of STIR were unchanged, not containing updated or new information. This limitation does not support the implementation of improved transfusion practices and best practices based on learned knowledge. Another limitation noted within the references is the lack of detail and clear guidance on who health services report adverse blood events to in each state and territory. This does not support the health service to report the event correctly and therefore does not contribute to current data and reports appropriately (O’Rourke, 2007). Lastly, another limitation critiqued in the evidence is that the guidelines are not specific to health service areas, such as a hospital ward or an outpatient clinic setting, such as the Australian Red Cross Lifeblood centre, as the requirements and procedures in an area may differ. This lack of information can hinder the implementation of improved transfusion practices and best practices. The reference critiqued from the standard was not based on small samples; all included findings were based on reports of adverse blood events from Australia-wide.

We also identified gaps within the evidence critiqued, such as underreporting. Underreporting adverse blood events due to factors such as lack of awareness, fear of blame, time constraints, and fatigue, as well as variations in reporting practices across health care facilities and different types of adverse events. Additionally, underreporting can be due to the lack of clarity in reporting procedures, near misses, and inaccurate data collection methods. Underreporting of adverse events can make it challenging to identify and address safety issues and update policies and procedures of best practice promptly. Another gap identified within the critique of evidence is the variability in reporting practices (ANZSBT & RCN, 2011). The guidelines are not tailored to different health care settings, such as a hospital ward or an outpatient clinic setting, like the Australian Red Cross Lifeblood centre. These discrepancies in protocols, definitions, and documentation practices across different facilities have a significant impact, leading to inconsistencies in reporting that directly affect patient safety. These gaps in reporting adverse events underscore the urgent need for attention to manage adverse blood events effectively.

Another gap that was found in the evidence that is being critiqued is the poor nature of engagement of the views of frontline healthcare workers in the guidelines formulation and report. Nurses’ voices are lacking in the literature because they are usually the first to see and react to transfusion-related incidents. Such an omission may lead to formulating policies that are less relevant or workable in real-world clinical settings (O’Rourke, 2007). Unless feedback is involved in guiding the stakeholders in transfusion processes, the guidelines may not cover such areas that determine a hindrance, like workflows or communication breakdowns, among other things. Closing this gap would result in more comprehensive, practical, and effective ways of enhancing the safety practices of transfusion.

Real-World Application (2.5 minutes)

• Describe how the standard is used in practice.

Action 7.07 is implemented via the hospital’s incident management system in a clinical setting. This is where clinical staff document all adverse events and near misses related to transfusions. It’s important to know that each hospital has different policies and procedures in regards to reporting methods. When an adverse event takes place, it is categorised individually according to the national haemovigilance criteria, then entered into a digital reporting platform, and then analysed by a specialised blood management committee. Then they are reported to external organisations such as the Therapeutic Goods Association, Australian Red Cross Blood Service, and pathology providers. This allows for data to be reviewed, enabling improvement and providing higher quality care to all patients (Australian Red Cross Blood Service, 2015). Every member of staff participating in the transfusion of blood and blood products must attend training on reporting adverse events related to transfusions by following the national guidelines and criteria.

• Use examples from your clinical placement (make sure to deidentify!), published case studies, or hospital policies.

I have not personally been involved in the process of reporting adverse transfusion events during my placements. However, I came across Akers (2022) article that discusses research using data from the Serious Transfusion Incident Reporting program. This analysis focused on administering RhD immunoglobulin and identified 21 incidents that posed risks to pregnant women. This example highlights Action 7.07, which relates to reporting adverse events in blood management. The research indicated that the causes of these incidents were primarily due to failures in communication and the misinterpretation of pathology results. Therefore, it is recommended to improve staff training, implement better protocols for interpreting results, and enhance communication among healthcare professionals. This example highlights the importance of this action and how it can influence the quality of care delivered to patients.

• Reflect on challenges and barriers nurses might face when implementing this standard.

Nurses may experience many potential barriers and challenges when implementing this action. These challenges can include delays in reporting events or instances where reports are not submitted, often due to the time constraints inherent in busy workplace environments. Additionally, the pressure of limited time may lead to documentation being overlooked, resulting in unaccounted for near misses (NBAHPWG, 2008). Another challenge may be that nurses are afraid to report due to penalties that may occur, as well as their reputation being damaged. Finally, another barrier is the lack of confidence among nurses when it comes to reporting adverse events, which may stem from insufficient education or challenges within the workplace environment. Throughout my various placements, I have observed how these barriers can significantly impact the reporting of adverse transfusion events. Therefore, making these challenges a reality in a clinical work setting.

Moreover, organizational culture can be identified as one of the main factors that either enable or do not support the implementation of this standard. In environments where open communication or a punitive attitude towards reporting of errors is lacking, nurses become demoralized from reporting errors. Such a fearful atmosphere may lead to the promotion of silence, which finally undermines patient safety (NBAHPWG, 2008). Also, the lack of a persistent management presence and understaffing may add to creating a stressful environment, and therefore, putting a real priority on reporting at the bottom of the list. Without management support and an open, non-punitive reporting system, even the well-intentioned nurses are unlikely to report incidences of transfusion, resulting in underreporting of the incidence of transfusion.

Evidence-Informed Recommendations (3 minutes)

Implement Mandatory Competency-Based Training

This is a recommendation that could improve the situation by having a mandatory, annually conducted, competency comprehensive training program on transfusion practice with clinicians. The CASP appraisal demonstrated a great range in the interpretation and reporting of adverse transfusion events in the interpretation and reporting of the staff, requiring standardised education (ARCBS, 2015). This is the latest best practice, and it fills the gaps between clinicians’ knowledge and confidence. Competency-based learning enhances the identification of adverse events earlier and decreases discrepancies between reporting, so patients have better outcomes and more precise data collection on the haemovigilance results.

National Standardized Electronic Reporting System

An electronic reporting system that is nationally standardized ought to be implemented in all healthcare institutions that participate in transfusions. According to our critique, which is affirmed by the ANZSBT (2025) and WHO (2005) guidelines, there was a lot of underreporting and discrepancies attributed to the paper-based systems at multiple sites (Australian Red Cross Blood Service, 2015). Centralisation of this process helps in enhancing the real-time monitoring, accountability, and benchmarking. The recommendation is a step towards the enhancement of the state of best practices and conforms to haemovigilance models across the globe. It also contributes to the current objective of the NSQHS 3rd edition of enhancing data quality and patient safety.

3. State-Specific Adverse Event Reporting Protocols

We suggest that the national guidelines ought to be changed to include clear guidelines by state with respect to the reporting of adverse transfusion events. The existing documents do not specify where to report and how, which compromises compliance as well as data consistency. This is a new way of thinking, and the idea is to reduce policy-practice gaps (NBAHPWG, 2008). Any special recommendations, depending on the particular healthcare environment (i.e., in an outpatient clinic or on a hospital floor), would benefit the compliance, clarity, and normal haemovigilance reportability.

Rating the Evidence (1 minute)

Conclusion (1 minute)

Conclusively, the critique noted some of the major gaps in the education of clinicians, the standardisation of the system, and the clarity of protocols that are preventing the full implementation of NSQHS Standard 7.07. The three recommendations we present are advancements that can be easily followed, which are: competency-based training, a national electronic reporting system, and state-specific guidance that could help in enhancing haemovigilance in the Australian healthcare setting. In line with the 3rd edition of the NSQHS Standards, the actions may result in the enhancement of the safety related to transfusions and the quality of national data, as well as the protection of patients against avoidable damage. These types of improvements are not optional; they are professional and ethical lures.

References

Australian and New Zealand Society of Blood Transfusion, & Royal College of Nursing Australia. (2011). Guidelines for the administration of blood products (2nd ed.). ANZSBT.

Australian Red Cross Blood Service. (2015). Blood component information: An extension of blood component labels. Australian Red Cross Blood Service .https://www.transfusion.com.au

 National Blood Authority Haemovigilance Project Working Group. (2008). Initial Australian haemovigilance report 2008. National Blood Authority. https://www.blood.gov.au

O’Rourke, M. (2007). The Australian Commission on Safety and Quality in Health Care’s agenda for improvement and implementation. Asia Pacific Journal of Health Management, 2(2), 21-25. https://journal.achsm.org.au/index.php/achsm/issue/download/93/123#page=22