Through its core work to review recorded patient safety events, the National Patient Safety Team identified an issue of delayed treatment for potentially life-threatening bleeds because of the time taken to authorise and obtain prothrombin complex concentrate products (PCCs).
PCC are human blood products recommended for use as first line treatment for major bleeding and reversal of the effects of some blood thinning medication (anticoagulants). Once the anticoagulant reversal decision is made, PCC should ideally be given within an hour. Delays or omissions in administration can result in serious patient harm or death.
A review of the National Reporting and Learning System (NRLS) identified examples of delays in obtaining PCC, due to poor communication, and in the processes for authorisation and ordering of PCC.
The team shared its insight with the UK haemovigilance scheme, Serious Hazards of Transfusion (SHOT), who subsequently highlighted the concerns directly with medical directors of trusts/health boards in the UK, as well as via their 2020 Annual SHOT Report.
In January 2022, SHOT published a Patient Safety Alert on Preventing transfusion delays which outlines specific actions to be implemented by organisations to prevent transfusion delays in bleeding and critically anaemic patients and to have agreed criteria where rapid release of PCC is acceptable without the initial approval of a haematologist.
About our patient safety review and response work
The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.
In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.
You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.
You can also find more case studies providing examples of this work on our case study page.