Over the last couple years, Children's has observed an undesirable trend of unintended and preventable pRBC transfusion events. Most frequently, these events have involved "over-transfusions," where the administered volume was larger than intended and/or a large-volume transfusion was associated with patient harm. We observe events like these approximately monthly, on average.
In partnership with various clinical teams and stakeholders, we are working on a long-term plan to reduce the incidence of over-transfusion through minor order changes and alerts that help clinicians pause to ensure accurate orders and administration in Epic. While this value stream analysis of the end-to-end transfusion process is still underway, we feel a sense of urgency to move quickly on immediate opportunities to help clinicians prevent over-transfusions.
Beginning Thursday, March 17
To provide clinical decision support that aims to reduce the incidence of over transfusions, we will add new best practice alerts in Epic to address the following aims beginning March 17. All of these aims have been specifically associated with over-transfusion events.
- Reduce the incidence of orders for greater than 20mL/kg of pRBCs
- Reduce the incidence of consecutive pRBC orders without an intervening Hgb
- Reduce the use of free text "max volume" comments in the orders.
Provider and clinician vigilance is always necessary, and our hope is that these Epic-integrated interventions will help reduce cognitive burden to better support all clinicians at the bedside.
Chief Medical Information Officer Evan Orenstein, MD, has prepared a brief presentation to familiarize care teams with the upcoming changes. Please take a few minutes to review this presentation before March 17. As a next step, we will continue to measure the effectiveness of these interventions and refine them over time as necessary using plan-do-study-act (PDSA) methodology.
Thank you for your support and feel free to contact Kim Murphy, 404-785-7802, with any questions or concerns.