The End

The first post on this blog was added on November 12, 2004 – it’s hard to believe I’ve been writing online about various aspects of healthcare for almost ten years.

When I started this site, originally named MSSPNexus, (Medical Staff Service Professionals) the focus of my writing was current news and standards pertaining to hospital medical staff administration.  Later, as my career took a different path, I added risk management and over the past few years patient blood management into the mix.

In 2004 being a healthcare blogger was a heady experience; there weren’t that many of us and we formed a sort of online friendship, especially through Nick Gene’s Medical Grand Rounds.  We were sometimes interviewed, either by one another or by traditional news media.  KevinMD came along in 2005, and his blog remains one of the best and most active medical sites on the web.  Nurse Kim’s Emergiblog was always a fascinating read.  Of note, she recently posted that she is shutting down her blog.  Dr. Mike Sevilla soon found that it is difficult to remain anonymous on the web, and he continues to write under his real name.  There were a host of others, many of whom contributed to the first grand rounds hosted on this site.

sunset_valleyOver the past couple of years Supporting Safer Healthcare has been sadly neglected.  There are many concerns about protected health information and social media, some justified, and some over-the-top paranoid.   We who write weigh every word and image carefully before posting.  There are also security issues, this blog was hacked by spammers a couple of years ago and had to be rebuilt from the ground up.

My current hospital position in bloodless medicine/patient blood management is fascinating and contributes to patient safety and good quality healthcare, although from a different perspective than medical staff administration and risk management.  I have learned more about the clinical aspects of healthcare, and my interactions with patients are often the most rewarding part of the job.  The down side is that the time and focus it requires can be a bit daunting.  I’ve been left with little creative energy for writing.

If I may offer one parting word of advice to everyone, find out of you are anemic and if you are, get treatment.  It’s often as simple as building up your body’s iron stores through changes in nutrition or iron supplements.  In many cases not being anemic (in other words, having a good blood hemoglobin count) is the single biggest protection against needing a blood transfusion during a hospital stay.  Research continues to mount showing that patients who do not need transfusions recover more quickly and with fewer complications.

Progressive hospitals everywhere are developing patient blood management programs that are designed to conserve a patient’s own blood supply and avoid the need for transfusion whenever possible.  In the hospital where I work the program is growing out of the body of knowledge acquired over the past 15 years of being a center of excellence for bloodless medicine patients, i.e., those who decline blood under all circumstances. Historically, that has been primarily Jehovah’s Witnesses, but others are now requesting our services in increasing numbers. If your hospital doesn’t have such a program encourage leadership to contact one that does.  There is also a professional society devoted to PBM, the Society for the Advancement of Blood Management, which offers professional education and resources.

It’s time to close this chapter of my professional career.  For those of you who have been readers of this blog for all or part of the past ten years, thank you. The older posts will remain online for now.  It has been my pleasure to be of some small service in sharing news and insights that affect both the delivery and safety of healthcare.  Many of you are gatekeepers for patient safety – a worthwhile role to be sure.  Keep up your good work. Patients, and at some point isn’t that all of us, need you.

Rita Schwab
MSSPNexus / Supporting Safer Healthcare


Choosing Wisely – Critical Care Societies Collaborative

Healthcare professionals tend, like everyone else, to make some choices based on habit or training.  The web site Choosing Wisely encourages physicians and patients to question some of those routine choices.

Choosing Wisely® aims to promote conversations between physicians and patients by helping patients choose care that is:

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary

One of the lists on the site is from the Critical Care Societies Collaborative; five things physicians and patients should question:

1.  Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.

2.  Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 g/dL.

3.  Don’t use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.

4.  Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.

5.  Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.

Read the explanations for these five recommendations here:


Did You Know?

There are numerous benefits to applying blood conservation principles in patient care, most often referred to as Patient Blood Management. For example:







New Patient Blood Management Certification Program Proposed by Joint Commission

The Joint Commission is developing a Patient Blood Management certification program for Joint Commission-accredited hospitals. Patient blood management incorporates a patient-centered approach into the blood utilization activities and blood conservation strategies that occur within the hospital. Blood conservation strategies minimize the need for blood transfusions.

Patient blood management applies to all patient populations from pediatrics to geriatrics. It also spans the entire continuum of patient medical care, including the management of anemia, minimization of blood loss, and optimization of coagulation, in addition to evidence-based transfusion.

Questions to Ask About Blood Transfusion and Heart Surgery

Conventional wisdom may lead you to believe you’ll fare better (during surgery) if you get a transfusion, but that’s not always the case, said Colleen Koch, MD, vice chair for research and education in cardiothoracic anesthesiology at the Cleveland Clinic in Ohio. In fact, heart surgery patients who receive blood transfusions tend not to do as well as those who don’t receive them, Dr. Koch noted.

During a coronary artery bypass graft (CABG) surgery, for example, a patient at one hospital might be given two units of blood, while doctors at another center may decide not to give a similar patient a blood transfusion.

Before you head to the operating room, it’s smart to ask your medical team about the likelihood of needing a blood transfusion and whether it can be avoided.

Read the rest of Questions to Ask About Blood Transfusion and Heart Surgery to see questions to ask prior to surgery.

Bloodless Medicine Lessons Learned: Benefiting All

surgeryBloodless medicine programs have been formed in hundreds of leading hospitals around the globe in the last 20 years.  Initially established to meet the needs of patients who decline transfused blood for religious or personal reasons, as healthcare consumers become more educated a growing number of patients are now requesting care without the use of donated blood whenever possible. 

What lessons in blood management have we learned during the past two decades?

Transfusion triggers have been lowered. 

In 1998 the “10/30 rule” (i.e., RBC transfusion indicated below a hemoglobin concentration of 10 g/dL or a hematocrit of 30%) was standard in most hospitals.  “There is now increasing evidence that RBC transfusions are associated with adverse outcomes and should be avoided whenever possible.” 1  

Most hospitals now use a transfusion trigger of around 8 g/dL hemoglobin.

The value of treating pre-operative anemia is more recognized

Studies have indicated that nearly 50% of patients entering an OR may be anemic at the time of incision. 

An article in The British Medical Journal stated “Previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality.  Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value.” 2

It is important to know your hemoglobin level, just like you know your cholesterol and blood pressure numbers.   

Many hospitals are moving toward patient blood management

An advisory committee of the US Department of Health and Human Services issued a letter in 2011 that stated, in part, “Blood transfusion carries significant risk that may outweigh its benefits in some settings and add unnecessary costs.  Improvements in rational use of blood have lagged behind improvements in the quality and safety of the products.”  3

Organization-wide patient blood management incorporates lessons learned in managing the care of bloodless medicine patients into improved care for all patients.


  1. Anemia and perioperative red blood cell transfusion: a matter of tolerance.  Crit Care Med 2006 May;34    (5 Suppl):S102-8. PMID:16617252
  2. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines  Br. J. Anaesth. (2011) 106 (1): 13-22. doi: 10.1093/bja/aeq361
  3. US Department of Health and Human Services Advisory Committee on Blood Safety and Availability


Thanks Specialty Care

I just want to say thanks to Specialty Care, provider of clinical services and quality benchmarking, and one of the vendors that suported the recent SABM Conference.

I stopped by their booth at the conference and entered their drawing for a Google Nexus 7″ tablet – and won!  Cool!

I’m enjoying the tablet, and want to thank Specialty Care for both the tablet and their support of SABM.

Routine Blood Transfusion-Not So Routine After All

Variant Creutzfeldt-Jakob disease (vCJD) is a rare, but deadly infection that can be transmitted in transfused blood or blood products.

An article in the UK Telegraph Killed by a needless blood transfusion, notes that Deryck Kenny, who died in 2003, was the first recorded death from vCJD traceable to contaminated blood.  His widow, a retired nurse, later reviewed his medical record and could find no documented reason for the three units of blood Deryck received during surgery for prostate cancer.  She concluded that it was simply the surgeon’s routine to transfuse patients.

Routine is a more common reason for transfusion than most would think.  As a result, hospitals around the globe are beginning to adopt patient blood management as a key safety concept.  The roots of the program lie in alternative treatments developed for patients who decline all blood transfusions in their care, in the past primarily Jehovah’s Witnesses, but now a choice that is being made by an increasing number of others as well.

For those anticipating a planned surgery, consider asking your physician to do a routine blood count in advance, and if anemia (low hemoglobin / hematocrit) is noted, to take steps to correct that anemia prior to surgery.  That simple step alone would eliminate the need for many transfuions during or after surgery.  In cases of mild anemia iron supplements may help, or if the problem is more pronounced, IV iron or medication that stimulates a patient’s own bone marrow to produce red cells, may be needed.

It has been said that “the safest transfusion is the one not given.”


New Perspectives on Transfusion from HHS

Findings of the U.S. Department of Health and Human Services Advisory Committee on Blood Safety and Availability, June 8, 2011:

  • Blood transfusion carries significant risk that may outweigh its benefits in some settings and add unnecessary costs.
  • Wide variability in use of transfusions indicates that there is both excessive and inappropriate use of blood transfusions in the U.S.
  • Medical advances and aging of the population are expected to drive demands for transfusions that could exceed supplies in one to two decades.
  • Improvements in rational use of blood have lagged behind improvements in the quality and safety of the products.
  • Additional data on blood utilization and clinical outcomes are needed to identify gaps in knowledge.
  • Programs at some hospitals have demonstrated significant reduction in blood use without increase in patient harm, based on expert decision-making