(P-QU-5) Addressing Patient Safety Event Reports for Active Electronic Platelet Therapy Plans

Background/Case Studies: A platelet therapy plan (PTP) involves standardized electronic orders for platelet (PLT) transfusions in oncology patients. These orders outline transfusion intervals, target goals, pre-medication, and provider notes. Authorized prescribers initiate PTPs, while oncology nurses activate them based on lab values and clinical status. Transfusion coordinators allocate PLTs based on daily rounds with oncology teams. Following a shift from universal 24-hour prospective oversight of PLT transfusions by transfusion coordinators, these transfusions were subject to daily retrospective review. Transfusion safety officers submit safety event reports for preventable PLT transfusions originating from PTPs.

Study

Design/Methods: We reviewed patient safety event reports specifically addressing preventable PLT transfusions from 1/1/2023 to 4/11/2024. Events were categorized according to clinical team feedback. Adverse events were identified through a review of the electronic medical record. Findings were shared during interdisciplinary meetings.

Results/Findings: Twenty-five patient safety event reports were identified and reviewed, with 24 undergoing analysis; one report was excluded due to a documentation error. A single PLT transfusion resulted in a documented febrile, non-hemolytic transfusion reaction, with minor to
no sequelae. The 24 report responses were categorized into 6 main groups (Figure A). Approximately 54% (n=13/24) were linked to ambiguous directives in PTPs, identified through feedback from Nursing leadership. An interdisciplinary team, comprising key partners from Oncology nursing leadership, the quality team, and stakeholders in Transfusion Medicine (i.e. medical director, transfusion safety officers, and coordinators), devised an SBAR (Situation, Background, Assessment, and Recommendations) response to address the issue. Inconsistencies were found in PTP orders, particularly in the interpretation of ‘daily’ as not uniformly equating to Q24 hours, contrary to other schedule intervals (e.g., Q12 hrs.). An initiative was launched to standardize PTP directive verbiage, update order sets to reduce product orders (e.g., from 2 to 1 PLT), and introduce electronic warning alerts for PTP frequency deviations. Ongoing staff education initiatives are being implemented to ensure proficiency in PTP use and information retrieval.

Conclusions: PTPs are a valuable resource when employed correctly. However, the risk of unwarranted activation poses a concern, potentially resulting in unnecessary PLT transfusions and associated adverse events. Departmental collaboration plays a pivotal role in mitigating these challenges and advancing patient safety. Despite their evident advantages, the adoption of PTPs varies among hospitals. Enhancing awareness and facilitating education are imperative to foster PTP optimal utilization.