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National Patient Safety Agency

NPSA publishes guidance to reduce delays in provision of blood and blood components for transfusion in an emergency

2 November 2010

The National Patient Safety Agency (NPSA) has issued guidance for all NHS organisations across England and Wales aimed at reducing delays in the provision of blood and blood components to patients in an emergency situation.


This latest Rapid Response Report (RRR) from the NPSA has been produced following reports of 11 deaths and 83 incidents, between October 2006 and September 2010, where the patient suffered harm as a result of delays in the provision of blood.


The RRR asks NHS organisations to ensure that:


• local protocols detail the roles and actions of clinical teams, laboratory staff and support services to enable timely access to the blood / blood components

• blood transfusion laboratory staff are informed of patients with a massive  haemorrhage at the earliest opportunity so they can activate the emergency procedures that are necessary to deal with the provision of blood in the event of an emergency situation. It is recommended that a trigger phrase is used to activate these procedures

• clinical teams dealing with patients with a massive haemorrhage nominate a member of the team to act in a liaison role with the laboratory staff and support services to avoid the potential for miscommunication and repeated calls to the laboratory by different people

• all incidents where there are delays or problems in the provision of blood in an emergency are reported and investigated locally, and reported to the NPSA and the Serious Hazards of Transfusion (SHOT) scheme.


Michael Surkitt-Parr, Clinical Reviewer for Patient Safety, said: “The NPSA has worked closely with experts to identify clear actions to support effective communication between the relevant staff and teams involved in treating a patient suffering a major haemorrhage.”


Dr Clare Taylor, Medical Director of SHOT said: "Blood transfusion saves lives. When a patient suffers from rapid major blood loss a number of different staff groups are critical to the outcome of management of the haemorrhage.  Consultants, junior doctors, biomedical scientists, nurses and porters must all be aware of the key decisions and actions required of them and effective communication and collaborative working between these staff is crucial.


"We have worked closely with the NPSA to develop this Rapid Response Report which urges organisations to review their systems and practices to ensure communication and teamwork during these emergency situations are effective and enable the rapid provision of blood components.”

For a copy of this latest RRR, please visit http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=83659



Notes to editors


1. Media enquiries to the NPSA Press Office:


Dominic Stevenson – 020 7927 9351 / dominic.stevenson@npsa.nhs.uk


Out of hours – 0788 411 5956


2. Following the publication of the Arms Length Body Review on 26 July 2010, the NPSA has stressed the importance for all NHS organisations across England and Wales to continue reporting patient safety incidents through the National Reporting and Learning System. This is so that trends in safety incidents can be identified and acted upon as early as possible.  This aspect of our work will continue within the new proposed structure of the NHS Commissioning Board and we will continue to work together in partnership with NHS organisations to make services even safer for patients.  We will continue to monitor the implementation of all patient safety alerts and guidance.