Blood Transfusion Error

Transfusion of blood saves life. An error in blood transfusion, at the same time, takes life. Blood samples can be autologous, in which the patient’s own blood is collected before surgery for possible use during or after surgery or allogenic, in which the blood is collected from donors. Clinical demand for blood is perennial and transfusion errors are accountable. This accountability of transfusion errors comes to light with the numerous reports on total blood transfusion errors. The discovery that HIV could be transmitted by blood transfusion in 1982 has given rise to strict regulations on blood donation and screening procedures. Apart from HIV, HBV and HCV risks have also been well addressed in blood transfusion process.

In spite of such strict clinical measures on blood transfusion, there are certain areas in transfusion process which requires acute attention. For example, the fatal acute haemolytic reactions to transfusion caused by ABO incompatibility have been attributed to administrative errors. The mismatch of blood units with that of the patient blood as a result of negligence is a serious cause of patient fatality. Apart from ABO incompatibility, contamination of red cells especially of bacterial origin is a matter of concern. Yersinia enterocolitica is a common organism found to cause contamination of red cells (Carson et.al, 1999). The infection of such organisms seems to be related to the storage period of blood units. Contamination of platelets is another serious cause where Staphylococcal infection is very common. Klebsiella and Serratia have also been detected in platelet contamination. Transfusion related acute lung injury is an acute respiratory distress occurring within hours after transmission, usually characterized by hypoxia due to pulmonary edema.

Error Prevention –Nurse’s Role

Nurses being responsible for the final bedside check before transfusion, have the final opportunity to prevent a mis-transfusion (Mole et.al, 2007). Blood products most often transfused by nurses include packed red blood cells, fresh frozen plasma, and platelets (Simmons P, 2003). An understanding and knowledge of the pathophysiology of transfusion reactions, symptoms and treatment is essential to safely administer and monitor transfusions (Labovich, 1997). A Failure Mode and Effect Analysis (FMEA) on the blood transfusion process to reduce the risk of problems inherent in the procedure has been developed recently to aid nurse decision making in the transfusion process (Burgmeier , 2002).Measures have been developed to analyze results and FMEA has been a valuable tool for error-trapping in the blood transfusion process. Transfusion error, resulting in the patient receiving the incorrect blood component, remains the largest risk related to transfusion. Nurses can increase compliance in high-risk areas of the transfusion process and reduce the potential for errors by developing accessible blood transfusion policies, auditable performance standards and training, and educational initiatives (Gray et.al, 2005).A Study to assess the effect of a simple intervention in the form of a tag on blood bags positioned in such a way that the nurses required to remove the tag to spike the unit reminding nurses to check the patient's wristband has shown that such a simple intervention is ineffective and there is a need for more stringent practice guidelines for the nurses (Murphy et.al,2007). Recently published guidelines highlight that most serious transfusion complications occur within the first fifteen minutes of transfusion and a close monitoring has been recommended before and fifteen minutes after commencement of each unit of blood (Rowe et.al,2000).The guidelines also recommend careful monitoring in the areas of sample collection, preadministration checking to avoid adverse reactions (Hainsworth,2000).  

The blood transfusion errors that often occur due to negligence of nurses include the following; 1.Samples being mislabelled with another patient’s identity.2.Blood being ordered for wrong patient.3.Other blood components being ordered for wrong patient.4.Blood sample being taken from wrong patient.5.patient given Rh D+ stock from the trauma refrigerator when Rh D-available. 6. Patient being transfused with unirradiated blood.7.Albumin being transfused to wrong patient.8.Autologous blood being discarded because of nurse’s failure to monitor patient for 4 hours and IV set not infusing.9.RN returning blood to OR refrigerator after being kept in the theatre for 12+ hours.10.RN leaving a unit of group B Rh D+ blood in trauma refrigerator for 12+ hours.11.Unit of RBCs missing from the OR refrigerator with no record of transfusion of the unit (Callum et.al, 2001).The prompt reporting of near-miss events of transfusion errors to improve transfusion safety has been elucidated in this study (Callum et al., 2001).The blood transfusion errors often includes administration of blood to wrong recipient, phlebotomy errors & blood bank errors including testing of wrong specimen. The most important of all errors has been the failure to detect at the bedside before transfusion of the wrong unit (Linden et.al, 2000). A recent study has identified 1.Patient misidentification. 2. Preliminary diagnostic errors and 3.Final diagnostic errors (Nakleh et.al, 1998) in blood transfusion.

A lack of awareness of good transfusion practice has been identified as a reason for poor compliance (Parris, 2007). A bar code patient identification system involving a hand-held computer for sample collection and for compatibility testing has been successfully evaluated recently (Turner et.al, 2003) to help nurses during blood transfusion. A decentralized phlebotomy skills Programme (Needham, 2001) and cross training in patient care skills on the nursing units has been found to be effective with reduction in errors of collection and labelling. Studies have proved that the effective and safe transfusion of blood depends on a series of linked processes and the safety measures a nurse should follow for blood transfusion includes donor selection and exclusion, post collection processing such as leuco-depletion and viral inactivation and neo technological innovations like the bar-code on the wrist band of each patient (Regan et.al, 2002).

Recent guidelines for blood transfusion direct that blood should not be transfused prophylactically and the threshold of transfusion is a hemoglobin level of 7.00 to 8.00 gm per deciliter. The safety directions include selection of donors; heat treatment; solvent and detergent treatment; methylene blue addition; leucodepletion; irradiation; minimizing donor exposure and the use of American plasma and Recombinant products(Goodnough et.al, 1999).Though viral inactivation of cellular products is not possible with heat, pooled plasma products can be pasteurized at 80° c for 72 hours. Solvent treatment can be applied to pooled plasma of up to 1000 donations. Methylene blue and ultraviolet B radiation can inactivate viral products and thus addition of methylene blue to single units of plasma followed by subsequent irradiation gives the advantage of not pooling the plasma. Modern leucocyte filters reduce the leucocyte count to less than 1x106. Leucodepletion seems to reduce nvCJD risks too (Shaughnessy, 2000).

 Conclusions

Published literature throws light on the consequences of blood transfusion errors and the element of human error involved in such wrong transfusions including administration to wrong recipient, phlebotomy errors, testing of wrong specimen and failure to detect at the bedside before transfusion of the wrong unit. A nurse, by profession has opportunities to establish policies and procedures, design nursing practices, and educate staff to help avoid blood transfusion errors (Bryan, 2002).  There is an urgent need of training programmes in nursing units that educate nurses on blood transfusion risk reduction, latest safety guidelines, nurse interventions and decision making. There is also a need for the nurses to be aware the recent advances and technological innovations in planning and management of transfusion medicine (Nagarajan et.al, 2002). Evidence based clinical guidelines for individual blood components, transfusion monitoring systems and quality assurance programs are vital to prevent blood transfusion errors.

References

• Bryan S (2002). Hemolytic transfusion reaction: safeguards for practice. J Perianesth Nurs. 17(6):399-403.
• Burgmeier J (2002). Failure mode and effect analysis: an application in reducing risk in blood transfusion. Jt Comm J Qual Improv.28(6):331-9.
• Callum et.al (2001).Reporting of near-miss events for transfusion medicine: improving transfusion safety. Transfusion 41:204-212.
• Carson J.L et.al (1999).Risk of bacterial infection associated with allogenic blood transfusion among patients undergoing hip fracture repair. Transfusion. 39(694).
• Goodnough et.al (1999).Blood transfusion – first of two parts .New Eng Journal of medicine, 340; 438-447.
• Gray A, Howell C, Pirie E (2005). Improving blood transfusion: a patient-centred approach. Nurs Stand. ; 19(26):38-42.
• Gregory A. Nuttall (2002).keeping a finger on the pulse of transfusion practices, ASA News Letter 66(12).
• Hainsworth T (2004). Guidance for preventing errors in administering blood transfusions. Nurs Times 100(43):45.
• Isbister JP (2002). Decision making in perioperative transfusion. Transfus Apher Sci. 27(1):19-28.
• Jeanne V. Linden et.al (2000).Transfusion errors in New York State: an analysis of 10 years experience. Transfusion.40 (10):1207.
• Labovich TM (1997). Transfusion therapy: nursing implications. Clin J Oncol Nurs.1(3):61-72.
• Mole LJ, Hogg G, Benvie S (2007). Evaluation of a teaching pack designed for nursing students to acquire the essential knowledge for competent practice in blood transfusion administration. Nurse Educ Pract.7(4):228-37. Epub 2006 Oct 31.
• Murphy MF et.al (2007).Prevention of bedside errors in transfusion medicine (PROBE-TM) study: a cluster-randomized, matched-paired clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check. Transfusion.47(5):771-80.
• Nagarajan SS, Chatterji K, Nandi M, Chaubey PC.(2002). Role of nursing in modern blood banking [in a tertiary level hospital]. Nurs J India. 93(6):122-4.
• Nakleh et.al (1998) Amended reports in surgical pathology and implications for diagnostic error detection and avoidance. Arch Pathol Lab Med 122(4): 303-309.
• Needham.P (2001).Reducing patient identification and specimen labelling errors through system and technical solutions, III National patient safety foundation, 212-219.
• Parris E, Grant-Casey J (2007). Promoting safer blood transfusion practice in hospital. Nurs Stand. 21(41):35-8.
• Regan et.al (2002).Blood transfusion medicine. BMJ. 325:143-147.
• Rowe R, Doughty H (2000). Observation and documentation of bedside blood transfusion. Br J Nurs. 9(16):1054-8.
• Shaughnessy (2000).Providing a safe and cost-effective blood transfusion service. Hospital pharmacist. 7(5):118-123.
• Simmons P (2003). A primer for nurses who administer blood products. Medsurg Nurs.12(3):184-90; quiz 191-2.
• Turner et.al (2003).Bar code technology: its role in increasing the safety of blood transfusion. Transfusion. 43(9):1200:2003.

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