Johns Hopkins All Children's Hospital Saint Petersburg, Florida, United States
Background/Case Studies: Fostering a culture of patient safety and minimizing patient harm has remained a central priority for Johns Hopkins All Children’s Hospital, a 259-bed pediatric hospital located in St. Petersburg, Florida. The hospital includes a 97-bed Neonatal Intensive Care Unit (NICU), 50-bed cardiac and pediatric ICU, 28-bed Bone Marrow Transplant (BMT) and Hematology/Oncology unit, 69 medical-surgical beds, and a specialized 15-bed Congenital Diaphragmatic Hernia (CDH) unit. To support this initiative, the formation of a Transfusion Safety Team began with establishing key roles critical to the program’s success. These included a dedicated Transfusion Safety Officer (TSO), working in close collaboration with a Transfusion Medicine Physician and Blood Bank Manager. Together, this multidisciplinary team laid the foundation for a robust Transfusion Safety Culture, extending from inpatient settings into outpatient clinics.
Study
Design/Methods: Early in the process, it became evident that an essential component was missing—engagement from frontline staff. These individuals, positioned to serve as champions or superusers within their respective inpatient and outpatient areas, were crucial to advancing transfusion safety efforts. Recognizing this, and following five months of groundwork by the TSO, the organization launched a Blood Champion Team to further enhance transfusion safety and quality practices across the system. This multidisciplinary, frontline team monitors transfusion related key performance indicators, including vital sign documentation, and is tasked with developing actions to sustain or improve.
Results/Findings: In collaboration with hospital leadership, a multidisciplinary team of 45 healthcare professionals (see Figure A) was formed to enhance transfusion safety. Key achievements include the development and implementation of a standardized transfusion checklist, along with routine audits and direct observations of blood product administration. These efforts have led to improved monitoring compliance for transfusion reaction monitoring including monitoring and documentation of vital sign —from 73% to 100% in several areas. The Transfusion Safety Team has also conducted over five patient safety reviews, including Root Cause Analyses (RCA), Apparent Cause Analyses (ACA), and other case evaluations.
Conclusions: The establishment of the Blood Champion Team has already demonstrated a measurable impact on the hospital’s transfusion safety culture. Enhanced communication between departments and improved compliance through data-driven initiatives are contributing to safer transfusion practices. Under the continued leadership of the Transfusion Safety Team, this initiative is poised to expand further and strengthen patient safety and quality of care across the continuum, particularly for our pediatric population.
