Monkey See, Monkey Do?

It’s December and the season to wind down. But sometimes, they just won’t let you. You sense a grave disturbance in the Force. The Dark Side is lurking just down the corridors of power, and you hear it’s mocking snigger giving way slowly to cackling, evil laughter. Ready ever to exsanguinate and impose great pain on you.

We are of course talking about the Blood Suckers Group (BSG) (oops, I mean Blood Services Group) of the Highly Soporific Authority (HSA) (oops, I mean Health Science Authority) and its latest circular to all Hospital Transfusion Committee Chairs and Hospital Laboratory Managers titled “The Need for 2 Separately Drawn Samples for Pre-transfusion Testing w.e.f. 1 Jan 2020″.

The BSG has just decreed that for all new patients (without prior records of blood grouping) for what we mortals know as Group and Cross Match or (GXM) will now need to submit TWO separately drawn blood samples taken on SEPARATE occasions which are preferably drawn by TWO persons.

This is to “detect and prevent ‘Wrong Blood in Tube’ (WBIT) errors”.

This Hobbit is given to understand that this requirement does not apply to restructured hospitals because they have already implemented “an electronic patient identification system” that is used “verification of blood samples meant for pre-transfusion testing”. Again, in plain mortal-speak, it means restructured hospitals have IT systems that can print patient stickers with patient-specific bar-codes.

For a start, these geniuses can improve their communication skills by taking lessons from Chewbacca.

But apparently, no private hospital in the Middle-earth have these fantastic sticker-printers that can print bar codes. So now, whenever a patient in private hospital needs blood, he has to be poked twice by two different people.

When one changes policy or implements a policy, there are trade-offs in costs and benefits which must be looked into and in this day and age, and explained to the affected parties (because in this day and age, affected parties are not morons).

  • For example, how many WBIT incidents and near misses have there been in the last five years? What is the average number of incidents per year?
  • How many GXM requests are there in a year from private hospitals? What is the additional cost of doubling this number of blood group testing?

Internally, one has to also conduct a cost-benefit analysis of this proposed new policy of poking everyone twice.

  • Give an imputed value to the value of a life saved (health economists can do that) by taking blood twice from each person.
  • Give an imputed value to the pain suffered for the additional blood sample taken
  • Give an imputed value to the possible complications (e.g. hematoma, infection etc) of venipuncture (low risk is NOT no risk).
  • Work out the manpower and material cost (reagents, supplies, biohazard waste disposal etc) of this additional testing requirement

Then deduct the costs from the proposed benefit and ask -does this still make any sense or cents?

While patient safety is a laudable aim in healthcare policy-making, there is cost to additional patient safety once we have achieved an acceptably high level of patient safety. It is naïve to think that patient safety has to be pursued at all costs (no matter how catchy that sounds) because there is a limit to resources. If we have unlimited resources, we can pursue something at all costs. But alas, the inconvenient truth is we don’t have unlimited resources and the healthcare budget is the fastest growing budget in government in the last 10 years and healthcare expenditure likewise is growing rapidly.

There are examples in the crime fighting world as well as the IT world where real people deal with stuff like limited resources. Law enforcers will tell you privately it is always impossible to eradicate ALL crime in society and some low level “ambient” level of crime is quietly allowed to exist. Of course, the police will usually and vigorously pursue all violent or serious crime, such as murder, robbery, kidnapping etc. Petty crimes such as pickpocketing, illegal money lending and debt collection, littering, speeding etc, they all exist to varying extents in societies and are seldom completely eradicated. This is because the cost of bringing all criminals and lawbreakers to justice is usually too high, not just in dollars and cents, but also from the perspective of the general population’s loss of peace and privacy.

In the IT world, when we buy or deploy a new IT system, let’s say a hospital IT system – If we specify that the IT system’s availability is rated at 99% (i.e. downtime of 1%), it may cost, say, $10 million dollars. But if you want the same system to have an availability of 99.9%, the price may go up to $12 to 13 million. You are paying an extra 20 to 30% for just an increase of 0.9% in availability from 99%. This also demonstrates the principle of diminishing return.

This hobbit suspects (100% speculation) that we are going to incur a lot of costs and inflict a lot of physical pain just because some genius decided that WBIT incidents should be eradicated. The problem is, one is not even sure poking a patient twice (especially by the same person, which is permitted but not encouraged) is even effective in eradicating all WBIT errors. But this hobbit also suspects, in the mythical realm of Middle-earth that bureaucrats live in and when “patient safety” is mentioned, the consideration of limited resources does not exist at all. But the hard truth is, outside of Middle-earth, even for a sacrosanct issue like patient safety, limited resources in terms of money, people and time are very real considerations. This hobbit further suspects that because the public hospitals are not affected because they can print the fancy patient stickers, private sector concerns were not addressed before this new policy was declared.

On 4 Dec 2019, a major private hospital group issued its own circular to all doctors practicing in its hospitals stating that the requirement to take two specimens of blood stemmed from the fact that HSA’s BSG was accredited to this organisation called AABB (American Association of Blood Banks) and that AABB required its members to follow this practice so as to remain accredited with it.

This makes the waters even murkier and begs even more questions. Last I heard, Singapore is a sovereign state and we do many things differently, like driving on different sides of the road. We also spell “organisation” with an “s”, not a “z”. The last time we tried doing things the American Way in healthcare, like Residency, it didn’t turn out well. So, if it is indeed an AABB requirement, then Singapore healthcare stakeholders must ask – what are the benefits of being accredited to AABB? Versus the costs? Not just benefits to HSA BSG, but to ALL Singaporeans and Singapore. Is our situation similar to AABB? Maybe there are many WBIT incidents in USA. What is the number of incidents per, say, 1000 GXMs? I.e. the rate of WBIT in Singapore vis a vis USA and other first world countries?

So many questions, so few answers. If the private hospital circular is factually correct and the private sector is doubling the number of blood specimens taken for GXM just to satisfy some bureaucrat’s desire to fulfill some obscure American accreditation requirement, then it is yet another case of monkey see, monkey do.

Actually wait, this hobbit stands corrected. Monkeys are actually quite intelligent.

 

 

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