module 7: errors in transfusion

Module 7: Errors in transfusion

Transfusion Training WorkshopKKM 2012

Sources of Error

Case 1

60 year-old man, hospital RN 721677

Post-BKA

Hb 7 g/dL

2 PC requested

Case 1 – cont’d

Sample and request form arrived at BB

BB staff checked sample and request form

Sample had a different patient’s name, IC and RN no.

Case 1 – cont’d

Patient requiring GXM

60 year-old man

Orthopedic ward 5C

Name: Mr YKC

Label on sample

28 year-old lady

Maternity ward 4D

Name: Mrs KB

Case 1 – what happened…

Patient requiring GXM

60 year-old man

Orthopedic ward 5C

Name: Mr YKF

RN 721677

Blood group O

Label on sample

28 year-old lady

Maternity ward 4D

Name: Mrs SW

RN 721667

Blood group AB

Always make sure the sample is labeled for the right patient

AT THE BEDSIDE with at least 2 patient identifiers

Name IC no

Best practice 1

Identify and inform patient Draw blood sample Label sample by

handwriting at bedside Collect or print sticker

label Check printed label

matches handwritten details before pasting on sample tube

Best practice 2

Print the patient’s sticker label

Identify correct patient

Inform patient (the need for transfusion)

Draw blood sample

Check label with patient

Stick label (at bedside)

Case 2

B/O RR, premature infant @ 27 weeks

Day 13 OL on ventilator

14th April 2011 @ 1235h: received GXM request

Grouped as AB Rh pos

Previous record: group O Rh positive

Re-grouping with second sample: AB Rh pos

Case 2 – cont’d

Possible explanation: 1st grouping was wrong

So BB staff went up to the ward

Bedside grouping: group O Rh positive

So what happened?

Case 2 – cont’d

What actually happened:

1st sample: Doctor A took blood sample Doctor B labeled the sample Doctor C filled and signed the request form

2nd sample: Doctor D took an unlabeled sample from

the fridge and sent to BB

The SAME doctor or staff who draws the blood sample must also label it

At the bedside

Just imagine if there was no previous record and this was a new patient

If this was an older child, he would have been transfused with AB blood when he is actually group O!

Case 3

28th March 2011: received a GSH sample for Supramaniam A/L Kannan

Grouped as A Rh pos

Previous record: Group O Rh pos

So what went wrong?

Case 3 – cont’d

There were 2 patients with the same first name in the ward

1.Supramaniam A/L Kannan Bed 16

2.Supramaniam A/L Solamalai Bed 23

Bedside grouping Patient 1: Group O Rh pos Patient 2: Group A Rh pos

Case 3 – cont’d

What went wrong:

Doctor A: filled the request form

Doctor B: drew the blood sample from the wrong patient

Doctor A: labeled the sample

How do we prevent errors?

Correct practice at every step

Step 1: the decision to transfuse Avoid inappropriate and unnecessary

transfusions

Inform patient

Fill up request form

Ask patient for blood group if known

Step 2: correct patient identification (prior to blood sampling)

Ask the patient his/ her full name and identification card no. (DOB and MRN)

Check the wrist band (in-patient) or hospital card/ ic (daycare)

Step 3: blood sampling

NEVER pre-label GXM tubes (EDTA) The SAME doctor/ staff must take blood

sample and label the tube NEVER use pre-printed labels Show labeled tube and completed

request form to patient NEVER take blood samples from >1

patient at a time

A

B

CD

Step 4: receipt of blood request BB staff must

make sure sample and request form are properly and correctly labeled

check for any previous transfusion record

Step 5: collection of blood

Bring collection slip and blood box BB staff must check collection slip matches

request form and blood to be collected Withdrawal of units must be documented

Staff name Date Time issued

Inspect colour and expiry date

Collection slip

Blood box ± ice

Clotted red cell Bacterially contaminated platelets

INSPECT – accept or reject?

Step 6: correct patient identification at bedside (prior to transfusion) Conscious patient

Ask patient’s full name and ic no.

Check against wrist band

Ask for blood group type if known

Check patient ID, form, blood unit and PPDK card matches

Unconscious patient Check wrist band Check patient’s

notes/ IC

Check patient ID, form, blood unit and PPDK card matches

Double check by second person

Bedside check

Step 7: monitoring vital signs

Transfuse blood/ components promptly (after correct bedside patient identification)

Check T0, BP and PR prior to transfusion

Re-check vital signs first 15 minutes and ½-1 hourly

Fill PPDK card AFTER completion of transfusion

Return PPDK card with used blood bags to BB

Monitoring vital signs Prior to transfusion Periodically

thereafter

Correct practice at every step from vein to vein

Ensures a safe transfusion

Vein to vein

But what happens when this practice fails?

NEAR MISSES - you’re luckyMEDICO-LEGAL CASES - no way out

Medico-legal issues

Wrong blood – wrong patient

The single most frequent error resulting in ABO-incompatible transfusion is the administration of properly labeled blood to a recipient other than the one intended

Linden JV, 1993

Case 4

50 year-old lady

c/o menorrhagia x 2 years

Hb 5.6

Film: iron deficiency anaemia

Diagnosis:

Menorrhagia 20 to DUB with chronic anaemia

Case 4 – cont’d

O/E: Pale Koilonychia

BP 140/85 PR 78

Chest: clear

No pedal oedema

Case 4 – cont’d

GXM 3 PC requested

2 PC transfused on night of 5th April 2007- uneventful

3rd PC commenced at 0400 on 6th April 2007

After 200mls, c/o headache, breathlessness, nausea and vomiting

Case 4 – cont’d

Blood transfusion stopped

Transferred to ICU

O/E: pale and tachypnoeic

BP 116/68 PR 98 T 400C PO2 75 mmHg

No urine output

Case 4 – cont’d

Diagnosis: Acute haemolytic transfusion reaction

Acute oliguric renal failure

Acute respiratory distress

Disseminated intravascular coagulation

Case 4 – cont’d

Management Ventilatory support Renal support with haemodialysis Blood support

13 units PC 24 units cryo 15 units FFP 26 random and 3 apheresis platelets= 81 donor exposures + 3 (PRBC)

Case 4 – cont’d

Patient survived

Discharged on 27th April 2007

On follow-up 1 year later, mild renal impairment and hypertension

No more menorrhagia

Case 4 – how error happened

HO checked blood and request form at nurses counter

2 patients requiring blood at the same time

HO ticked ✓ and signed checklist form at counter

Case 4 – how error happened

No bedside check done

Nurse in charge did not double check

Patient group O given A blood, the other patient group A given O blood

The verdict – medical negligence

Case awarded a substantial amount

In the news…

Contaminated blood

Wednesday November 14, 2007Ex-teacher awarded RM450,000By EMBUN MAJID

ALOR STAR: A former Quran teacher, who sued the Government over the HIV-contaminated blood she received during a transfusion seven years ago at Jitra Hospital, has been awarded RM450,000.

Case 1

SEGAMAT, JOHOR: Felda settler Norizan Ismail died last Friday, four years after allegedly contracting HIV in hospital.

Norizan, 46, of Felda Palong Timur, is believed to have been infected with HIV during a blood transfusion at Segamat District Hospital. She was later diagnosed HIV-positive.

Case 2

But …

Major risks of transfusion

The major risks of transfusion currently lie in the clinical use of blood in hospitals, rather than with transmission of infectious agents through the supply

Stephen Review 2001

Inappropriate and Unnecessary (I&U) transfusions Hébert et al:

unnecessary transfusions: 4 to 66%

The SANGUIS study: transfusion rates depend more on

physicians than on type of procedure, patient population or hospital

SHOT 1996 – 2011

Back to basics – key lesson

An emphasis again on the importance of the essential steps of the transfusion process: taking the blood sample from the correct patient correct laboratory procedures issuing of the correct component and identification of the right patient at the bedside at

the time of transfusion Identification of the correct patient remains a

key issue and that this must become a core clinical skill

Improving communication & handoverSHOT report 2011

NEAR MISSES TRANSFUSION ERROR

2010 6 3 1

2011 12 2 1

2012 9 7 1

2013 11 5 -

2014 ( till Feb)

2

WARD BLOOD BANK

NEAR MISSES/ TRANSFUSION ERROR HOSPITAL AMPANG 2010-2014 (Feb)

Blood bank data, Ampang hospital

Ampang Hospital (2012)

Transfusion error Error occurred in haematology ward Wrong blood given to patient by new SN No bedside check done Error realised when another SN wanted to

transfuse blood to another patient Patient group B pos, transfused group O pos

blood

7 Steps to a Safe Transfusion

Inappropriate & unnecessary (I&U) transfusions can result in a major transfusion reaction, morbidity and mortality!

Module 6- case 1 (post-partum, iron deficiency anaemia)Module 6- case 3 (dengue fever)Module 7- case 5 (menorrhagia, iron deficiency anaemia)

The next time you decide to transfuse

Stop, think and ask yourself …

Is it really necessary?

The end