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director ibgrl 1966 1975 to err human evolution transfusion safety hospitals dr derek norfolk transfusion 2012 relatively safe we we going every system perfectly designed achieve exactly results gets systems health care evolved years designed achieve particular objectives don berwick director us institute healthcare improvement a scientific truth triumph convincing opponents making see light because opponents eventually die a generation grows up max planck physicist the heroism a doctor paris 18

experienced enfeebled red cell storage affect patient outcome james p aubuchon md president chief executive officer puget sound blood center professor medicine laboratory medicine university washington seattle washington experienced enfeebled experienced enfeebled red cell physiology the storage lesion 0 0 concentration concentration 100 100 80 80 60 60 40 40 20 20 atp atp dpg dpg 2 4 6 2 4 6 storage period wks storage period wks 12 24 0 12 24 0 post transfusion period h post transfusion period

factors associated platelet wastage scottish hospitals wells aw gray a bailie k forrester k stewart a afb operations group scottish national blood transfusion service platelet supply changes 80 apheresis platelets bactalert testing delayed release recalls 5 7 shelf life hospitals holding platelet stocks scotland 12 months august 12 23 191 platelets booked 15 6 transfused source account blood ebma reports monthly report scottish hospitals total red cell platelet issues wastage hospital monthly pl

are major haemorrhage protocols effective audit 4 major trauma centres curry n hemmatapor s lawn m cantwell c okukenu e allard s behalf london haematology trauma group major haemorrhage protocols npsa report 2010 delays provision emergency blood 11 deaths 83 incidents harm trauma 9 mhp activated trauma uk observational data demonstrate mhps may improve survival up 26 may reduce mof sepsis johansson stensballe vox sang 2009 96 111 8 riskin et al j coll surg 2009 209 198 205 cotton et al j trauma

national comparative re audit bedside transfusion practice bbts 27th september 2012 mrs susan cottrell transfusion practitioner mrs vicki davidson transfusion practitioner mr john grant casey project manager oct dr megan rowley project clinical lead 2011 national comparative audit blood transfusion 2011 bedside transfusion re audit introduction aims audit audit standards methodology participation sample size findings recommendations conclusion acknowledgements national comparative audit blood tr