Published on 24 May 2023

NSQHS: Standard 7: BLOOD MANAGEMENT BULLETIN MAY | 2023

  • Introducing the Blood Management 'Fab 5'

    The ‘Fab 5’ team are multi-disciplinary leads brought together to ongoing NSQHS Standard compliance to Blood Management safety.

    The Fab 5 Team is:

    Team Lead: Jo Mapes

    Quality Lead: Nicky Timms

    Education lead: Saiu King (Cindy) Lie

    Subject Matter Expert: Slav Curcic, Blood management CNC Western Health

    Medical Lead: Bill Renwick

  • Do you have any questions?

    For any queries about Blood Management you’d like to direct to the NSQHS Std 7 Fab 5 or others, please contact BestCare@wh.org.au

  • Like to know more about Accreditation Readiness?

    Visit our Live Best Care site at https://westerly.wh.org.au/livebestcare/  or use the following QR Code to find out more about NSQHS Standard Readiness.

From Jo

As part of Accreditation Readiness activity, a NSQHS Standard of the Fortnight initiative has been introduced. This involves a focus on one Standard per fortnight, with communications and walkarounds to help staff be aware of how Best Care at Western Health reflects this Standard, to ask staff possible Surveyor questions and answers, and to walk in a Surveyor’s shoes to see what WH practice looks like.

We are excited that NSQHS Standard 7: Blood Management is to be the focus of the sixth Standard of the fortnight. This will run from Monday 29 May to Sunday 11 June. Look out for friendly Best Care Co-ordinators, Fab 5 team members and other staff who will pop into clinical areas/departments to talk with you about Blood Management.

The Blood Management Standard aligns with Right Care and aims to ensure that patients’ own blood is safely and appropriately managed, and that any blood and blood products that patients receive are safe and appropriate.

The Blood Management Standard supports Western Health to provide Right Care.

Western Health’s comprehensive approach to Blood Management draws upon requirements of this Standard and supports the monitoring, review and improvement of coordinated care. Programs and strategies to help support Blood Management include:

  • Integration of Bacchus Marsh and Melton procedures into Western health processes and Policies
  • Increased focus on patient identification
  • Recommencing patient satisfaction surveys to ensure consent and understanding about receiving blood and blood products

Our ‘Fab 5’ team have brought together nursing, medical, education, and quality expertise to support our ongoing compliance with NSQHS Std 7. We are working closely with Western Health’s Blood Management and Safe Care Committee to ensure we are continually monitoring, reviewing and improving coordinated and safe care for patients.

The good news is we are already providing Best Care and living up to the requirements of NSQHS Std 7 on Blood Management in our everyday work! It is why we performed exceptionally in the 2020 Accreditation Survey. This year’s Survey is simply a chance to show once again how well we provide safe care at Western Health.

Please continue reading to find out more about our communicating for safety strategies, achievements and opportunities for improvement, as well as resources to help you to be Accreditation Ready for NSQHS Std 7.

Jo Mapes
NSQHS Std 7 ‘Fab 5’ Team Lead
Director of Nursing & Midwifery, Footscray Hospital
Division: Perioperative and Critical Care

Resource Centre

The following resources have been put together to support staff to be aware of the NSQHS Blood Management Standard and Accreditation Ready for Survey against this Standard:

Improvement Initiatives

There are multiple improvement initiatives underway to improve Blood Management. Do you know about these?

  • Mandatory training on We learn.
  • Managing Blood Transfusion reactions – procedure for clinical staff.
  • Correct patient identification checks.

Achievements and Opportunities

We are proud of…

  • Completion of Blood Safety mandatory training increasing across the health service.
  • Embedding Blood safety training into all induction programs for medical and nursing staff at WH.
  • The integration of WH forms and processes at Bacchus Marsh hospital.
  • The systems and processes embedded to ensure safe transport and administration of blood and blood products across WH.

We are looking forward to…

  • Continuing to align WH process at Bacchus March and Melton and through the Pathology Tender process.
  • Reintroducing patient satisfaction surveys on transfusion of blood and blood products.

Our focus continues on…

  • Optimising patient’s own blood to manage pre/perioperative anaemia.
  • Safe process for any changes of patient ID details in the context of the massive transfusion protocol.

 

 

Key Messages

 

Data Analysis

  

Key Messages
Blood Management and Safety WH target for mandatory Blood Management training is at 90% Let’s reduce the risk of adverse events with blood or blood products by:

  • Completing the we Learn module relevant to your role.
  • Ensuring you understand the Blood management policy and procedure.

Ensure you know the correct process for blood and blood products storage, prescribing and administration.
 Correct patient ID processes Patients must be correctly identified prior to blood or blood products being ordered, prescribed or administered.
  • Ensure patient identification checks are completed prior to pathology ordering or samples being labelled/sent.
  • Scan patient wrist band and pathology printer labels where available.

Ensure patient ID is confirmed and checked prior to administering any blood or blood products.
Safely manage any adverse reactions to blood or blood products All reactions or adverse outcomes must be reported.
  • Escalate care if any adverse reaction occurs.
  • Document any reaction.
  • Report events in Riskman.

Return blood bags to the Blood Bank following any patient reaction for analysis.
Ensure no blood or blood products are wasted unnecessarily Blood and blood products must only be used when indicated and wastage must be avoided through correct storage, prescribing and administration.
  • Only prescribe blood or blood products as clinically indicated.
  • Ensure all products are collected when required and stored under the correct conditions.
  • Only administer when patient is ready and the transfusion can be safely completed.

Ensure any unused products are returned to blood bank.