Module Code: TLM16
Module Title: Leading and Managing Programmes of Learning in Professional Education
Leading and managing change in clinical practice: A critical analysis and evaluation of policy implementation in blood transfusion practice in an acute setting.
Course: PG Diploma in Education
Word Count: 3,315
The change in nurse education from apprenticeship training to the higher education setting has raised concerns about the lack of practical skills newly qualified nurses have on registration (NMC 2005). In blood transfusion practice for example, every practitioner must be competent to administer blood components safely however, the Serious Hazards of Transfusion (SHOT) scheme have consistently demonstrated that ‘wrong blood’ incidents are a major cause of morbidity and mortality related to transfusion in the United Kingdom. As a result the SHOT working group have recommended that all practitioners should have their clinical competency formally assessed.
Transfusion of blood and blood components remains essential for medical practice but is subject to a number of concerns. Its management involves a complex sequence of activities and, to ensure the right patient receives the right blood, there must be strict checking procedures in place at each stage. Several publications including the SHOT annual reports demonstrated that receiving the wrong blood was the commonest risk associated with blood transfusion (McClelland and Phillips, 1994; Ottewill, 2003; SHOT, 2005).
SHOT is a national, anonymous reporting scheme for the serious sequel of blood components. Since its launch in 1996, the SHOT report (2006) acknowledged that there have been a total 2717 incorrect blood component transfused (IBCT) incidents, resulting in 18 deaths and 91 cases of major morbidity, (Appendix1). Incorrect ordering, prescribing, and incorrect management of adverse reactions of transfusion have all been identified as major contributing factors associated with IBCT. As such initiatives offering a range of long and short-term strategies to ensure blood transfusions are carried out safely have been launched by the government. The publication by the Department of Health, of three Better Blood Transfusion Health Service Circulars (HSC 1998; 2002; 2007), the introduction of transfusion standards in the Clinical Negligence Scheme for Trusts [(CNST) now known as the National Health Service Litigation Authority (NHSLA)] making blood transfusion training mandatory and a rigorous national haemovigilance programme via the National Blood Service (NBS) are examples of such initiatives.
Furthermore, in November 2006, the National Patient Safety Agency (NPSA), in collaboration with the Chief Medical Officer’s National Blood Transfusion Committee (NBTC), the Department of Health (DH) and Serious Hazards of Transfusion (SHOT) developed and published a safety notice; Safer Practice Notice 14, Right Patient Right Blood (SPN 14 – appendix 2) to address the main risks of blood transfusion. The notice, directed to chief executives of all NHS and independent sector, states that by May 2007 organisations responsible for administering blood transfusions in England and Wales should have:
1. Agreed to and started to implement an action plan for competency-based training and assessment for all staff involved in blood transfusions. 2. Ensured that the compatibility form (or equivalent) and patient notes are not used as part of the final check at the patient's side. They should comply with their blood transfusion policy, which stipulates that, the final identity check must be done next to the patient by matching the blood pack with the patient’s wristband (or identity band/photo identification card). 3. Systematically examined their local blood transfusion procedures, using formal risk assessment processes, and appraised the feasibility and relevance of using:
a) bar codes or...
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