Article Text

Download PDFPDF
  1. T Zee,
  2. D Thomas,
  3. N Jannaway,
  4. S Bassey
  1. Blood Transfusion, Royal Cornwall Hospital, Truro, UK


Objectives & Background Patient Identification is fundamental to the success of safe transfusion. ABO incompatible blood transfusion has been classed as a Never Event by the Department of Health.

In 2014, 680 Wrong Blood in Tubes (WBIT's) were reported nationally to SHOT (Serious Hazards of Transfusion). National Guidelines have changed (2013) to improve accuracy in sample labeling (two sample rule) but SHOT reports prove on going noncompliance with this procedure.

Blood samples are rejected if ANY aspect of the labeling is incorrect. This can generate rejection rates for transfusion specimens >10%. Over 3000 samples were rejected in 2014 at RCHT. This results in loss of patient confidence due to repeated clinical procedures, delay to treatment, loss of staff time, and increased cost of equipment and reagents.

Llama Safe is a unique application that enables healthcare professionals to guarantee positive patient identification and accurate transfusion sample labeling at the bedside. The decision to pilot the application in the Emergency Department (ED), beginning Jan 2015, was due to:

  • Above average Tx samples rejected;

  • Large multidisciplinary teams with high staff rotation;

  • Unpredictable workload and stressful environment;

  • 60–70 thousand patients per year;

  • Poor adherence to labelling at the patient's bedside, including Wrong Blood in tube events annually;

Methods Prior to the pilot, two months were spent shadowing a multitude of clinical staff in the ED to fully understand the sampling processes and the problems that arise.

A simple system was designed in collaboration with ED staff, containing minimal steps, ensuring all safety measures had been considered and satisfied.

Llama posters and stickers were placed throughout the department to remind staff to use the new labelling system.

Results Staff were extremely invested and supportive in the Llama implementation allowing the pilot to be smooth and successful.

ED very quickly took it upon themselves to cascade training and encourage the implementation on other wards.

No WBITs have been identified in ED since the introduction of Llama (18 months).

Rejections in ED have reduced 10 fold with Llama labelled samples, consequently improving patient care and proving concept for full roll out.

Conclusion With appropriate planning and collaboration, introducing new technology into an acute environment can be easily achieved.

Staff pressure has been relieved from a tense clinical environment.

Llama was very positively received in the ED.

  • Trauma

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.