A review of paediatric and neonatal prescribing practice. Tracey Shackleton Alder Hey Children s NHS Trust 24 th September 2014

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1 A review of paediatric and neonatal prescribing practice. Tracey Shackleton Alder Hey Children s NHS Trust 24 th September 2014

2 SHOT report 2013 The overall pattern of errors reported to SHOT for the 2013 report is similar to previous years.

3 2013 has seen a significant reduction in IBCT (WCT) reports whereas the incidence of IBCT (SRNM) reports remains identical to the previous year.

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5 Non irradiated red cells were issued by the laboratory to child undergoing bone marrow who needed irradiated blood components. The units were transfused. This occurred on 4 separate occasions. A 2 year old was prescribed 20 ml instead of 203 ml as a result of using Hb in g/dl in a transfusion calculation formula designed for Hb in g/l.

6 10 kg child brought into A&E after vomiting blood. Hb 98 g/l. Wrongly diagnosed with acute arterial bleed O RhD neg blood prescribed in units, not ml/kg Given a total of 4 units (1122 ml), the first 3 given at a rate of a unit per 20 minutes, and subsequently continued to receive the 4th unit despite normalisation of his heart rate and blood pressure. Post transfusion Hb 270g/L Attempted venesection difficult. Required transfer to a paediatric intensive care unit and made a full recovery.

7 Post operative 8 yr old cardiac patient bleeding excessively and requiring to return to theatre. 6 units ordered. 6 paedipacks were issued when in fact the request was for 6 adult units. Over transfusion of a neonate following the wrong weight being recorded on the prescription chart. 9 year old transfused 3 adult units rather than 1 adult unit following miscommunication. 3 year old sickle cell child with pre transfusion Hb of 43g/L was transfused 2 adult red cells. Post transfusion Hb 151g/L. A repeat Hb had been requested following the first unit but was clotted and never repeated before the second unit was given. Child required venesection.

8 BCSH administration guidelines The prescription should include the following information: patient core identifiers date (and time if appropriate) the blood component transfusion is required type of blood component to be administered any clinical special transfusion requirements e.g. irradiated, CMV seronegative, blood warmer required volume or number of units to be transfused (exact number in mls for paediatric transfusions) time over which each unit is to be transfused (rate or exact length of time over which the specified volume is to be transfused for paediatric transfusions) any special instructions e.g. concomitant drugs required, such as furosemide signature of the prescriber

9 Audit Summary

10 62 hospitals contacted to request blood transfusion prescription charts. If different charts for paediatrics and neonates then those included as separate charts. 31 charts returned but a number were not scanned well enough to collate data. 24 prescription charts were reviewed. 37 data points were collected for each chart.

11 Prescription charts varied immensely Single use/multi use Blood transfusion specific/ multi purpose Different versions for neonates/paediatrics Basic charts.extremely informative charts Booklets/single sheet

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14 Patient demographic Lead Consultant Blood group Weight Gender n = 24 Ward Hospital NHS number Hospital Number DOB Name

15 Special Requirements/Consent and previous transfusion reactions. Consent Information leaflets Previous tx reactions n = 24 Blood warmer Tx drugs Irradiated CMV neg

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17 Observations Extended set End n = minutes Baseline

18 Tx No: Base 15mins 30mins 1 hour 2 hour 3 hour 4 hour 1 Baseline date/time 2 Baseline date/time 3 Baseline date/time 4 Baseline date/time 5 Baseline date/time TEMP HR BP RESP TEMP HR BP RESP TEMP HR BP RESP TEMP HR BP RESP TEMP HR BP RESP

19 Prescription Clinical indication Duration Rate Volume (units/mls) n = 24 Volume (mls) Volume ( units not specified) ***** Product Prescriber (signature) Prescriber (print name) Time of prescription Date of prescription

20 Paediatric red cell NCA Paediatric prescriptions Red cell National (1302) prescription % N Known Prescribed*: mls 59 (740/1264) Paedipacks 4 (49/1264) Units 39 (493/1264) *In 18 cases more than 1 type was prescribed

21 Why does prescribing in mls matter? Unit of blood could mean adult or paediatric pack and could result in over transfusion. 18 month-old child prescribed 3 units, intending paedipacks. Given adult units. Hb 21.6 g/dl, venesected.

22 Other information Formulas Bleep No n = 24 Contact name Informed lab Tx reactions

23 Other pieces of information found on blood transfusion prescription charts: Advice on investigation of transfusion reaction Management of transfusion reaction R codes IV access check record Anticoagulation reversal protocol Transfusion checklist Best practice

24 Conclusions Huge variations across the country many different formats and levels of information. 1/3 of hospitals are not documenting the need for CMV negative and irradiated blood products at the point of prescription. There are a large number of hospitals allowing for prescription in units or not specifying what the measurement of volume should be. The weight of the patient is being included on many charts but should only be documented on single use charts. If the weight is being put on a document that would cover a number of transfusions over a period of time then this weight may not reflect a patients true weight when calculating amount of product required. Potential to under dose a patient.

25 Information at the point of prescription regarding consent, information leaflets and previous transfusion reactions is not consistent. Time of prescription is not recorded on the majority of charts Just over 50% of charts had a clinical indication for the transfusion recorded. Blood group on the prescription chart could be useful if used as part of the bedside check.

26 Do we need to stipulate more clearly what should be included as part of a prescription document? Do we need a standardised prescription chart? What are the key elements for a safe prescription?

27 Using your keypad please type in the numbers (0-9) AND order of the top 5 most critical pieces of information that you feel should included on a blood transfusion prescription chart. 13% 1. Current weight 20% 6% 12% 20% 3% 11% 6% 7% 2% 2. CMV negative/irradiated requirements 3. Blood group 4. Clinical indication 5. Volume in mls 6. Volume in units 7. Rate / duration 8. Obs chart 9. Time of prescription 10. Formulas (press 0 only on handset)

28 Acknowledgements Dr Helen New Consultant in Paediatric Haematology and Transfusion Medicine Imperial College Healthcare NHS Trust/NHSBT Suzanne Gilardoni Senior PA to Dr Helen New All the hospitals that sent charts to be included in the audit Thank you