Background/contextDespite Choosing Wisely recommendations for single unit red blood cell transfusion orders, ~50% of orders on the oncology ward at London Health Sciences Centre (LHSC) were for two units. The oncology ward at LHSC is a 60 bed tertiary care unit. In mid 2016, LHSC was 18 months into its implementation of computerised provider order entry (CPOE).Aim/objectivesBy December 2017, increase the proportion of one-unit red cell transfusion orders on the oncology ward from 50% to 80%MeasuresOutcome: % one-unit red cell transfusion orders (aggregated monthly).Improvement/innovation/change ideasOur initial theory was that unawareness of the guidelines (established in 2014) and subscription to the obsolete doctrine of two-unit transfusions were the primary behavioural drivers. Initial change ideas included an educational/awareness blitz including rounds presentations, memos and posters. Failure led us to revisit our hypothesis and carry out a real-time audit, where our team was notified on each two-unit transfusion. This revealed the true root cause: the overwhelming majority of two-unit transfusions could be traced back to standing orders that were entered on an admission order set. After provider engagement, we proceeded to remove all admission order sets containing two-unit transfusions.Impact/lessons learned/resultsAfter order set removal, our one-unit transfusion rate rose to 86% and was sustained for 17 months. We learnt two primary lessons. First that CPOE and poor order set design combined to perpetuate poor ordering practices. Second that revisiting our hypothesis and engaging in thoughtful root cause analysis that included direct observation ultimately led to an effective, sustainable solution.Discussion/spreadOur study underscores the importance of executing root cause analysis on a microsystem level. We would expect the factors driving poor performance to be completely different on a service such as general internal medicine. Our study also highlights the potential pitfalls of CPOE and the importance of regular order set review to ensure adherence to current evidence.

Background Platelets are the most commonly discarded blood product in Canada, with the most common cause of in‐date product loss being improper storage. Transport containers to maintain temperature and extend acceptable return time may represent a method to reduce wastage. The objective of this study was to evaluate the impact of a validated Platelet Transport Bag (PTB) on platelet wastage. Study Design and Methods Thirty‐six hospitals with the highest platelet discards were invited to participate in a before–after observational study. Hospitals were instructed to utilize a validated 4‐h PTB for clinical situations where immediate transfusion was not planned. Five hospitals audited in‐date platelet discards from July 2018 to November 2019 to characterize wastage causes. In‐date platelet discard data 12 months before and after the start date for each site were analyzed to determine changes in wastage. Results Of 36 hospital sites, 16 agreed to participate. Pre‐ and postdiscards were 277 and 301, respectively, for all sites combined. There were no significant before–after change in wastage rate (+0.05%, p = .51). Fifty discards were included in the detailed audit; the most common reasons were return to the blood bank after more than 60 min outside a PTB (n = 17, 34%) and return in a red cell cooler (n = 10, 20%). Conclusion Implementation of PTB did not improve wastage. Common causes of in‐date discards were return after 1 h outside of a PTB and placement in a red cell cooler in error. Further research is required to investigate potential strategies to mitigate in‐date platelet wastage.