The national investigation
Delays in the administration of emergency blood transfusions as part of neonatal resuscitation may result in hypoxic brain injuries or early neonatal death. Early intervention can improve the likelihood of survival and outcome.
HSIB have identified issues with the communication of maternal risk factors for neonatal blood loss and with the recognition of the need for a blood transfusion as time critical treatment.
As an example, which is referred to as ‘the reference event’, the investigation reviewed the care of a mother and baby where significant blood loss was identified and an emergency delivery of the baby took place. However, the need for immediate transfusion of the baby was not recognised resulting in a delay in this intervention. The baby died at 2 days of age.
This investigation will:
- Understand the context and contributory factors influencing communication regarding blood loss between teams in a dynamic working environment.
- Identify the systemic factors that help or hinder staff in decision making when considering the administration of a blood transfusion during neonatal resuscitation.