title: An order set and checklist improve physician transfusion ordering practices to mitigate the risk of transfusion-associated circulatory overload.
abstract: OBJECTIVE
  There are few studies of quality interventions to mitigate the risk of transfusion-associated circulatory overload (TACO). Our aim was to reduce TACO risk in patients admitted to internal medicine at our hospital, by addressing gaps in transfusion practice.
  
  
  METHODS
  A 3-month baseline audit of red blood cell (RBC) transfusion orders was conducted. An intervention consisting of a transfusion order set and physician checklist was developed and implemented based on identified gaps, followed by a 3-month post-intervention audit. Compliance with appropriateness criteria for RBC transfusion was ascertained, along with documentation of transfusion rate, diuretic usage and consent.
  
  
  RESULTS
  A total of 97 transfusion orders from 68 inpatients and 95 orders from 62 inpatients were audited in the baseline and post-intervention groups, respectively. Compliance with appropriateness criteria was similar pre- and post-intervention (87 versus 85%, P = 0·81). Specification of transfusion rate improved (84 versus 98%, P < 0·01), and diuretics were appropriately ordered more frequently for patients with TACO risk factors (37 versus 64%, P < 0·01). Timing of diuretics shifted from between or post-transfusion to pre-transfusion (35 versus 86%, P < 0·01), without increases in hypokalemia or acute kidney injury. No case of TACO was observed during the study. Documentation of specific risks discussed during consent discussion improved (4 versus 23%, P < 0·01).
  
  
  CONCLUSIONS
  A checklist and order set are tools that can improve the quality of transfusion orders by increasing the judicious use of pre-transfusion diuretics and augmenting the specification of transfusion rate. These interventions could be adapted to electronic order formats to improve transfusion safety.
authors: Department of Hematology, University of Toronto, Toronto, Canada.
authors: E
authors: E
authors: Tseng
authors: Faculty of Arts and Sciences, University of Toronto, Toronto, Canada.
authors: J
authors: J
authors: Spradbrow
authors: Sunnybrook Health Sciences Centre, Institute for Clinical Evaluative Sciences, Toronto, Canada.
authors: X
authors: X
authors: Cao
authors: Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Canada.|Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.
authors: J
authors: J
authors: Callum
authors: Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Canada.|Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.
authors: Y
authors: Y
authors: Lin
mesh_terms: D000328:Adult; D000368:Aged; D057189:Checklist; D017707:Erythrocyte Transfusion / Q000009:adverse effects / Q000379:methods* / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged
keywords: TACO; checklist; diuretics; patient safety; red blood cell