Click here to access the SHOT transfusion delays investigation tool document, or access via the link below.
Transfusion delays investigation tool
What is this document about?
The document contains a set of tools that can be used during the investigation following a transfusion delay to identify contributory factors. The tables are provided in an editable format and can be adapted to local practices to ensure all aspects are covered, issues identified, and preventative actions implemented. These resources have been developed to help teams identify causes of delay and are not mandatory.
The document brings together tools and resources to support reviewing patient safety events with transfusion delays and promote learning from these events. It aims to help identify underlying causes, enhance system-level understanding, and drive improvements to ensure timely, safe, and effective transfusion practice.
The steps have been mapped in order of transfusion process but can be amended to fit local requirements.
Table 1 is for patient information gathering.
Table 2 is a general timeline for the transfusion pathway.
Table 3 is for identifying contributory factors to the transfusion delay.
Table 4 is to identify areas of learning and improvement opportunities.
Local teams can evaluate which tables would be beneficial to transfusion delay investigations within their organisation; not all tables may be required. Tables can be amended to fit local requirements. This document has been developed as a prompt to complement existing local processes.
Who is it for?
These tools are particularly aimed at transfusion teams but can be utilised by any person responsible for the investigation of transfusion delays.
SHOT anticipates that there is not one size fits all to processes and pathways within different organisations, and as such have provided an editable version for teams to build and develop an investigation tool that works to identify gaps and weak points in local steps and processes.
In table 3, blank boxes have been provided to enable the user to add any additional observed contributory factors.
Why is this document needed?
The number of transfusion delays reported to SHOT are increasing annually, with some leading to significant patient harm. Consideration of all aspects of the transfusion pathway, and identification of contributory factors can aide investigators to strengthen practices, reduce error recurrence and improve transfusion safety.
How has it been developed
This document has been developed by the SHOT team with input from key stakeholders from both clinical and laboratory backgrounds. The SHOT team would like to extend their sincere gratitude to all who have contributed to this document.