Your Never Events, Never Ever with Blood360

• MSoft’s Blood360, Sample360 and PPID360 working together so your Never Event will Never Ever happen in your Hospital.  The solutions stop the never event “Transfusion of ABO-incompatible blood components” from happening. They also stop the Never Event Misidentification of patients, however, this has been removed from the latest list of Never Events but is still a recommended desirable.

“Transfusion or transplantation of ABO-incompatible blood components or organs

Unintentional transfusion of ABO-incompatible blood components.

• • • Excludes where ABO-incompatible blood components are deliberately transfused with appropriate management.

Unintentional ABO mismatched solid organ transplantation.

• • • Excluded are scenarios in which clinically appropriate ABO incompatible solid organs are transplanted deliberately
    • In this context, ‘incompatible’ antibodies must be clinically significant. If the recipient has donor specific anti-ABO antibodies and is therefore, likely to have an immune reaction to a specific ABO compatible organ then it would be a never event to transplant that organ inadvertently and without appropriate management.”

Taken from: Never Events List 2015/16 Link

Guidance:

Safer Practice Notice – Right Patient, Right Blood, 2006, available at Link 

SHOT Lessons for clinical staff, 2007, available at Link

SHOT Lessons for Clinical Staff 2009, available at Link