Development and evaluation of trigger tools to identify pediatric blood management errors

Area of Science:

• Transfusion Medicine
• Patient Safety
• Health Informatics

Background:

• Pediatric Patient Blood Management (PBM) programs need continuous error surveillance.
• Current PBM programs predominantly use passive surveillance methods.
• Active surveillance is needed to improve the detection of PBM errors.

Purpose of the Study:

• To develop and evaluate automated trigger tools for active surveillance of pediatric PBM errors.
• To identify and prioritize candidate trigger tools for all transfused blood products.
• To estimate the rate of PBM errors and associated adverse events.

Main Methods:

• Utilized the Rand-UCLA method with expert consensus to identify triggers.
• Developed automated queries for electronic health record (EHR) data.
• Manually reviewed cases and calculated positive predictive values (PPV) for trigger tools.

Main Results:

• Identified 28 potential triggers, developing 5 automated tools (e.g., positive patient identification, missing irradiation, over-transfusion).
• PPV for ordering errors ranged from 38-100%.
• Over-transfusion by volume was linked to adverse events not captured by passive surveillance.

Conclusions:

• Automated detection of pediatric PBM errors via EHR data is feasible, enabling active surveillance.
• Over-transfusion represents a significant cause of harm in pediatric patients.
• Active surveillance systems are crucial for enhancing pediatric patient safety.