Article Text

Download PDFPDF

Reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative
  1. Alan Gob1,
  2. Anurag Bhalla1,2,
  3. Laura Aseltine3,
  4. Ian Chin-Yee2,3
  1. 1Medicine, London Health Sciences Centre, London, Ontario, Canada
  2. 2Medicine, University of Western Ontario, London, Ontario, Canada
  3. 3Pathology and Laboratory Medicine, London Health Sciences Centre, London, Ontario, Canada
  1. Correspondence to Dr Alan Gob; Alan.Gob{at}


Background/context Despite 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/objectives By December 2017, increase the proportion of one-unit red cell transfusion orders on the oncology ward from 50% to 80%

Measures Outcome: % one-unit red cell transfusion orders (aggregated monthly).

Improvement/innovation/change ideas Our 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/results After 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/spread Our 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.

  • control charts/run charts
  • healthcare quality improvement
  • implementation science
  • information technology
  • root cause analysis

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

View Full Text

Statistics from


  • Contributors AG and IC-Y were involved in all aspects of study design, analysis and manuscript preparation. AB was involved in survey of root cause analysis, educational interventions and initial draft of manuscript. LA was involved in data analysis in all phases of the project and review draft manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.