Learning about the points of failure
We recently came across a white paper published by MaxQ Research LLC that breaks down the transfusion blood supply chain into “7 critical steps,” as illustrated in their infographic. What was interesting to us is that the white paper discusses how in each of these steps “possible points of failure where any delays, miscommunications, or procedural issues can cause serious problems.”
Over the years, based on what we’ve learned from you, many past VUEPOINTs have focused on the fact that it’s the time blood products are out of your (blood bank) control where these delays or procedural issues can result in problems. It’s for this very reason that many of you believe using an irreversible temperature indicator is the only way to know for certain that temperatures never exceed the 6oC or 10oC standard.
Before you dive into the entire white paper, which we encourage you to do, here are some key sections in the white paper’s introductory pages that we’d like to highlight, particularly when considering temperature indicators like Safe-T-Vue:
p. 5: Returned Blood and Blood Components
“Often there will be a need to return blood, blood components, to the blood bank/transfusion service. This is possible only if:…
- The appropriate temperature has been maintained….
- The records indicate that the blood, blood component, tissue or derivatives have been inspected and that they are acceptable for reissue.”
While a qualified and validated storage/transport container validated for up to 24 hours may be used, there are well-known “points of failure in the blood supply chain” caused by human error. If the blood product is removed from the storage container or cooler and left at room temperature, which happens in both the ER and OR, the blood could reach unsafe temperatures. An irreversible temperature indicator like Safe-T-Vue is the only way to know if this exposure has occurred. Use of an infrared thermometer or other temperature measuring device is not an adequate inspection method as the blood product may have been returned to the cooler and re-cooled – after having exceeded temperature standards.
p. 8: Cost of Blood Wastage is Significant
“Not only are blood products costly, but unnecessary losses or spoilage can result in shortages and put human lives at risk. A more reliable and cost-effective solution is needed.”
Need we say more?
As the white paper points out, in 2010 the estimated direct cost of one unit of RBCs was $225.42, and this doesn’t account for overhead costs. And then there is the truly unquantifiable cost and risk of a unit of temperature-compromised blood being transfused into a patient.
Learn more about blood transport packaging
You can download the white paper PDF and learn more about what hospitals and blood banks are using for shipping and storage today as well as the science behind these containers.
Many thanks to MaxQ Research for authoring and sharing this white paper. They would be delighted to entertain your questions and hear your reactions to their work.
As always, we also welcome your comments and questions, and appreciate the work that you do to maintain quality and integrity in your blood supply chain.
p.s. The bibliography on the last page of the white paper is an excellent resource, be sure to check it out.