Small changes make a difference

Introduction: In March 2020 SARS-Covid 19 halted access to clinical areas thus direct access to staff and patients handwritten case records. NHS Scotland Transfusion Practitioners (TP) and Hospital Transfusion Teams (HTT) struggled to elicit information to complete incident reviews. Most HTT's were using SHOT questionnaires for each event/reaction and found multiple communications required to gather the smallest piece of information. Often senior staff in clinical areas (e.g. Charge Nurses, Consultants, Clinical Directors and Managers) were overwhelmed and struggling to translate clinical information to incident reviews. To ensure timely, appropriate information gathering and reporting the TPs recognised a need to modify interactions when investigating clinical reactions and events with clinical teams. Method: The SNBTS Transfusion Team Haemovigilance Working Group applied a Plan-Do-Study-Act (PDSA) test of change cycle following analysis of NHSS Service-Now clinical incident trends available from all NHSS health boards. This identified seven common recurring incident trends Anti-D, ADU, HSE, ICBT-SRNM, RBRP, WBIT and TRALI/TACO. The group then utilised the information from the relevant SHOT questionnaires in addition to applying an understanding of the clinical thought process to produce bespoke Incident investigation forms, which facilitate straightforward information gathering and review. These are in MSWord format that are easily pre populated prior to sending and are readily attached to incidents in local Risk Management Systems. Results: The SNBTS TT Haemovigilance Group produced nine Incident Investigation Forms. These forms lay out information requests in an intuitive manner for clinical teams to record information and findings. The group found the Incident Investigation forms facilitate straightforward information gathering during review of reactions and events, reducing the requirement for multiple requests from large, small, near or remote sites. Conclusion: When the TP role was first created, the TP's were deemed the essential link between the laboratory and clinical areas often translating one discipline to the other. Nowadays, we find ourselves in a similar situation. As such small and helpful changes supporting efficient and effective data gathering supports clinical areas, risk management and haemovigilance.