Resilience in the blood transfusion process: Everyday and long-term adaptations to ‘normal’ work

Blood transfusion is considered one of the safer aspects of healthcare, however potentially avoidable patient-safety incidents led to 14 deaths in the United Kingdom in 2017. Improvement initiatives often focus on staff compliance with standard operating procedures, which fail to understand adaptations made in a complex, dynamic environment. Therefore, the aim of this study is to examine the extent and nature of adaptations at all stages of the full vein to vein transfusion process. Thirty-seven employees described sixty-six adaptations in their transfusion practices, showing clear differences between what has been characterised as work-as-imagined (WAI) and workas-done (WAD). An analysis of the adaptations using the Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0) shows that triggers for adaptations were mostly staff-related or driven by poor information technology systems, but the resultant adaptations were usually amendments to tasks and processes. The majority of adaptations (83%) were forced - ideal solutions are not possible, so workarounds and coping strategies are required, but some (17%) were proactive - the surrounding system is adequate, but performance is improved by adapting. Managers or colleagues were largely unaware of the adaptations made (79%) and, as a result, opportunities may be missed to identify and learn from resilient practices. The Concepts for Applying Resilience Engineering (CARE) model was further articulated in order to shed Page 2 of 27 extra light on triggers and mechanisms. We make a number of suggestions regarding how we can better learn from adaptations and how these could be used to improve the safety of the blood transfusion process.