Blood Transfusion Errors Research Articles

The impact of a closed-loop electronic blood transfusion system on transfusion errors and staff time in a children's hospital.

To assess the impact of a closed-loop electronic blood transfusion system on transfusion errors and staff time. Before and after study in all wards of a children's hospital, involving patients and staff of all the wards. The changes were closed-loop electronic blood transfusion, barcode patient identification, electronic blood transfusion administration records and error pop-up warning. The main outcome measures were percentage of blood transfusion errors, time spent on transfusion tasks. Transfusion errors were identified in 3.87% of 2556 blood transfusion orders pre-intervention and 0.78% of 2577 orders afterwards (P<0.01). Phlebotomists, nurses, and physicians may make mistakes, including wrong blood type when apply for blood, wrong patient when blood draw or transfusion, wrong dose when apply for blood and the wrong tube label when blood draw or cross-matching, which are significantly reduced after change (1.09% vs 0.31%, 1.13% vs 0%, 0.31% vs 0%, 1.33% vs.0.78%, P<0.01). Time spent on blood apply was 5.3±1.2min, hand over blood bag at the transfusion department was 14.9±1.4min and blood transfusion was 15.8±2.4min. Time per transfusion round decreased to 2.6±1.0min, 6.3±1.6min and 9.3±2.2min respectively (P<0.01). A closed-loop electronic blood transfusion, barcode patient identification and error pop-up warning reduced transfusion errors, and increased confirmation of patient and blood types identity before transfusion. Time spent on blood transfusion tasks reduced.

Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses

Introduction: Blood transfusions are lifesaving treatments which require critical attention to processes and details. If processes are not followed, grievous errors can lead to sentinel events. A review of investigations completed due to reported events will show the error trends associated with systems used throughout the blood transfusion process. Methods: This study employed root cause analyses (RCAs) within the Veterans Health Administration (VHA) to review the events leading to blood transfusion errors. Data was pulled from the RCA databases within the VA National Center for Patient Safety. The time frame was October 2014 to August 2019. A total of 53 RCAs and aggregated reviews were included in the study. These were reviewed for common themes and gaps present within processes. Results: The most common events fell within the categories of incorrect or delayed blood orders, incorrect or lack of patient identification, and wrong blood given. The RCA for each event was reviewed and studied. The RCAs had a crossover of multiple causes; lack of a formal process, communication barriers, and technology barriers were the most frequent. Conclusion: These RCAs express great variation between VHA facilities, such as process created, number of staff reports, and number of RCAs completed. Lack of standard practices nationwide, training barriers, and technology barriers may explain the variation of transfusion errors throughout the VHA. This study brings to light questions about standardization of transfusion protocols. Future study regarding such standardization is necessary to determine its plausibility.

Relationship on Leadership Support with Nurser Compliance Identifying Patients in the Implementation of Patient Safety in Datu Beru Central Aceh Regional General Hospital

The patient safety mission at the hospital is to prevent patient safety incidents from occurring, the number of incidents is said to be like an iceberg phenomenon. The incidence rate in Indonesia based on data from the Joint Commission International (2012) shows that as many as 13% due to surgical errors and 68% due to blood transfusion errors. This study aims to analyze the relationship between leadership support and compliance with nurses in identifying patients in the implementation of patient safety in the Datu Beru Aceh Hospital. Tengah. The research design used a quantitative analytic survey with a cross-sectional design. The population of all nurses working in the Women's Internal Medicine Room at Datu Beru Hospital, Central Aceh was 34 people. The sampling technique used total sampling. Data analysis was carried out by univariate, bivariate and multivariate with chi_square. The results of the research variable Leadership Support with Nurse Adherence obtained p-value = 0,000, meaning that there is a relationship between leadership support and nurse compliance to identify patients in the application of patient safety. Multivariate analysis of leadership support variables obtained sig value of 0.000 &lt;p = 0.05, which means that there is a significant influence of the leadership support variable on nurse compliance. There is a relationship between leadership support and the compliance of nurses to identify patients in the application of patient safety and there is a significant effect.

Prevalence and Types of Medical Errors at a Trauma Center in Isfahan, Iran (2018-2019)

Introduction: Clinical errors can affect patient safety, reduce the quality of care, or even cause irreparable harm to the patients. Attention has been primarily tended to be directed toward medication errors; accordingly, limited focus has been placed on other clinical errors, such as caring, therapeutic, and blood transfusion errors. Regarding this, the present study was aimed to perform a comprehensive investigation of the type and prevalence of different clinical errors in a teaching trauma hospital. Materials and Methods: This descriptive study was targeted toward the evaluation of the types and frequency of medical errors in the Trauma Center of Ayatollah Kashani Hospital in Isfahan, Iran, during 2018 and 2019. The data were collected using a clinical error reporting form, covering such data as the type of error, error severity, and associated ward. The data were analyzed in SPSS software, version 16. Results: A total of 375 errors were reported, the majority of which were related to imaging and radiology domains (26.7%), followed by laboratory and blood bank (22.9%). In terms of job position, nurses (42.6%) and physicians (29.5%) made the majority of the errors. Furthermore, most of the errors occurred in the morning shifts (57.3%) and at the hospital emergency department (28.9%). Conclusion: According to the results of the present study, the emergency department requires more attention to reduce the documentation errors of radiology and imaging.

A survey of blood transfusion errors in Aichi Prefecture in Japan: Identifying major lapses threatening the safety of transfusion recipients

BackgroundDespite recent progress in blood systems, transfusion errors can occur at any time from the moment of collection through to the transfusion of blood and blood products. This study investigated the actual statuses of blood transfusion errors at institutions of all sizes in Aichi prefecture. Materials and methodsWe investigated 104 institutions that perform 98 % of the blood transfusions in Aichi prefecture, and investigated the errors (incidents/accidents) that occurred at these facilities over 6 months (April to September, 2017). Incident/accident data were collected from responses to questionnaires sent to each institution; these were classified according to the categories and risk levels. ResultsNinety-seven of the 104 institutions (93.3 %) responded to the questionnaire; a total of 688 incidents/accidents were reported. Most (682 cases; 99.2 %), were classified as risk level 2; however, 6 were level 3 and over, which included problems with autologous transfusion and inventory control. Approximately one-half of the incidents/accidents (394 cases; 57.3 %), were related to verification and the actual administration of blood products at the bedside; more than half of these incidents/accidents occurred at large-volume institutions. Meanwhile, a high frequency of incidents/accidents related to transfusion examination and labeling of blood products was observed at small- or medium-sized institutions. The reasons for most of these errors were simple mistakes and carelessness by the medical staff. ConclusionsOur results emphasize the importance of education, operational training, and compliance instruction for all members of the medical staff despite advances in electronic devices meant to streamline transfusion procedures.

Medical error reporting software program development and its impact on pediatric units' reporting medical errors.

Objective:The purpose of this quasi-experimental study was to developing web-based, anonymous reporting system to increase reporting of medication errors, blood transfusion errors and patient falls in pediatric units and to compare the computerized system with the written system already in use at the institution.Methods:This study was conducted in all pediatric units of a research hospital. All physicians and nurses working in these units agreed to participate in the study. All units were visited to introduce the new reporting system. The number and quality of the reports sent on the new system in years 2014 and 2015 were compared to the reports sent the previous year using the written system.Results:There was considerable increase in rates of reporting: 234% increase in medication error reporting rate, and 100% increase in the reports of blood transfusion errors. One of the most important results of this study that near-miss errors were not reported at all while the written system of the study institution was being used, whereas it was the most commonly reported type of errors in the electronic error reporting system.Conclusion:The web-based reporting system, which makes reporting easy, promoted the development of safety culture among doctors and nurses in common language.

Implementation and Effectiveness of a Bar Code-Based Transfusion Management System for Transfusion Safety in a Tertiary Hospital: Retrospective Quality Improvement Study.

BackgroundLarge-scale and long-term studies are not sufficient to determine the efficiency that IT solutions can bring to transfusion safety.ObjectiveThis quality-improvement report describes our continuous efforts to implement and upgrade a bar code–based transfusion management (BCTM) system since 2011 and examines its effectiveness and sustainability in reducing blood transfusion errors, in a 3000-bed tertiary hospital, where more than 60,000 prescriptions of blood transfusion are covered by 2500 nurses each year.MethodsThe BCTM system uses barcodes for patient identification, onsite labeling, and blood product verification, through wireless connection to the hospital information systems. Plan-Do-Study-Act (PDSA) cycles were used to improve the process. Process maps before and after implementation of the BCTM system in 2011 were drawn to highlight the changes. The numbers of incorrect labeling or wrong blood in tube incidents that occurred quarterly were plotted on a run chart to monitor the quality changes of each intervention introduced. The annual occurrences of error events from 2011 to 2017 were compared with the mean occurrence of 2008-2010 to determine whether implementation of the BCTM system could effectively reduce the number of errors in 2016 and whether this reduction could persist in 2017.ResultsThe error rate decreased from 0.03% in 2008-2010 to 0.002% in 2016 (P<.001) and 0.001% in 2017 (P<.001) after implementation of the BTCM system. Only one incorrect labeling incident was noted among the 68,324 samples for blood typing, and no incorrect transfusions occurred among 67,423 transfusion orders in 2017.ConclusionsThis report demonstrates that continuous efforts to upgrade the existing process is critical to reduce errors in transfusion therapy, with support from information technology.

Assessing protocol adherence in a clinical trial with ordered treatment regimens: Quantifying the pragmatic, randomized optimal platelet and plasma ratios (PROPPR) trial experience

BackgroundMedication dispensing errors are common in clinical trials, and have a significant impact on the quality and validity of a trial. Therefore, the definition, calculation and evaluation of such errors are important for supporting a trial’s conclusions. A variety of medication dispensing errors can occur. In this paper, we focus on errors in trials where the intervention includes multiple therapies that must be given in a pre-specified order that varies across treatment arms and varies in duration. MethodsThe Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial was a Phase III multi-site, randomized trial to compare the effectiveness and safety of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with a 1:1:2 ratio. In this trial, these three types of blood products were to be transfused in a pre-defined order that differed by treatment arm. In this paper, we present approaches from the PROPPR trial that we used to define and calculate the occurrence of out of order blood transfusion errors. We applied the proposed method to calculate protocol adherence to the specified order of transfusion in each treatment arm. ResultsUsing our proposed method, protocol adherence was greater in the 1:1:1 group than in the 1:1:2 group (96% vs 93%) (p<0.0001), although out of order transfusion errors in both groups were low. Final transfusion ratios of plasma to platelets to red blood cells for the 1:1:1 ratio group was 0.93:1.32:1, while the transfusion ratio for the 1:1:2 ratio group was 0.48:0.48:1. ConclusionsOverall, PROPPR adherence to blood transfusion order pre-specified in the protocol was high, and the required order of transfusions for the 1:1:2 group was more difficult to achieve. The approaches proposed in this manuscript were useful in evaluating the PROPPR adherence and are potentially useful for other trials where a specific treatment orders with varying durations must be maintained.

Cause analysis and preventive measures for blood sample errors

Objective To study the reason and preventive measures of inconformity of the extraction appeared in the process of transfusion blood specimens with the patient's blood type. Methods The reasons of transfusion errors why extracting required blood type was not consistent with the patient's blood type examplesa in Zhengzhou transfusion of hospital from 2008 to 2012 were retrospectively analyzed. Results The experimental results showed that blood specimen inconformity was 49.60%, the error rate of blood extraction and blood infusion was 31.20%, infusion error only was 15.20%, blood type change after stem cell transfusion was 4.00%. Reasons of blood type change after stem cell transplantation to extract blood samples mainly included the blood center or blood did not accord with logo type blood stations provided(16.13%), blood use application form to fill in error(20.97%), check the wrong blood type (6.45%),blood samples taken(29.03%), the blood sample tag(27.42%). Conclusion In order to ensure the safety for clinical use must adopt measures to prevent resolutely put an end to a blood transfusion errors. Key words: Blood sample errors; Blood transfusions; Bloodtype

Assessment of blood administration competencies using objective structured clinical examination

In order to minimise the risk of blood transfusion errors, all healthcare professionals who participate in the transfusion process are required to be assessed as competent. New and innovative methods of training and competency assessment are required to improve the training process. The aim of this study was to explore the use of objective structured clinical examination (OSCE) in the assessment of competencies for blood administration. A mixed-methods approach was employed using structured observations of simulated practice through a three station OSCE to assess three stages of the blood transfusion process: (i) communication; (ii) documentation and (iii) identification of patients and blood products. Nurses and midwives were assessed using a 28-item checklist that was rated on a 5-point Bondy scale. After the OSCE, a questionnaire was given to participants to evaluate their attitudes. Eighty four midwives and nurses from 10 different clinical areas in a District General Hospital in London. Inter-rater reliability between assessors was high (>0.8). Overall assessors scored participants highest on aseptic technique (97%) and lowest for positive patient identification (81%). Participants felt that the OSCE was a useful intervention and could contribute to improving the competences of staff in blood transfusion safety. A simulation OSCE is valid and reliable for competency asessment in blood administration. The checklist is simple to complete and can be used to identify weaknesses and evaluate learning needs of staff in blood administration.

Transfusion errors and management

Error is an inherent component and an intrinsic by-productof every activity in which humans are involved. This ten-dency to err is philosophically perhaps one of the definingtraits that characterize us as human beings. Transfusionerrors probably existed once blood transfusion became anessential component of medical treatment. However, thesystematic acknowledgement, recognition and analysis ofthese errors are certainly a much more recent phenomenon.According to an Institute of Medicine (IOM) reportreleased in 1999 [1], medical errors are one of the leadingcause of death in the US and have caused an estimated44 000–98 000 deaths per year, which is soberingly morethan the motor vehicle accident death rate of 43 458 forthat particular year.Errors and adverse events carry a high financial burden.The Agency of Healthcare Research and Quality (AHRQ)estimated that the cost of medical errors resulting inadverse events is approximately $37AE6 billion per year, and$17 billion of those costs are preventable [1]. Significantly,the AHRQ has reported that medical errors are not onlybecause of medication errors but can result from bloodtransfusion errors, misdiagnosis, misinterpretation of labo-ratory results with incorrect therapy, equipment failure,hospital acquired infections or misinterpretation medicalorders.Looking specifically at transfusion mortality, Schmidtreviewed 69 records of deaths labelled as transfusion mor-tality and concluded that 31 (44AE9%) were directly attribut-able to transfusion, of which 25 were due to red cellincompatibilities and discrepancies [2]. Myhre reviewed113 records fatalities reported to the Food and DrugAdministration (FDA) as a sequelae of blood or blood prod-uct transfusion from 3 April 1976 to 31 December 1979 [3].Thirty-three fatalities were due to post-transfusion hepati-tis, and three involved plasmapheresis or leucopheresisdonors. The remaining 77 cases were of three categories:the vast majority were preventable errors: 47 cases (61%)were due to ‘‘clerical errors’’ such as drawing the wrongblood specimen or giving the wrong unit of blood to thepatient; 8 cases consisted of genuine errors that occurred inthe laboratory and 22 miscellaneous cases.Many other recent reports exist with the majority retro-spective and involving registry data (e.g. reporting to theFDA). Honig and Bove listed 70 fatalities, 38 of which weredue to transfusion errors [4]. Camp and Monaghan studied126 FDA reports from 1976 through 1980. They found that64 reactions that were due to simple clerical errors, such asgiving the blood to the wrong patient [5].In a landmark paper, Sazama and colleagues studiedtransfusion-related deaths reported to the US FDA for10 years and identified 131 fatal ABO incompatible trans-fusions. The study showed that the most frequent errorleading to a fatal outcome was administration to someoneother than the intended recipient [6]. Records of transfusionerrors in the New York State for the past 10 years (Linden)showed that erroneous blood administration was observedin 1 out of 19 000 RBC units administered. Half of theseevents occurred outside the blood bank (administration tothe wrong recipient, phlebotomy errors, testing of thewrong specimen, transcription errors and issuance of thewrong unit) with 15% of cases involving multiple errors [7].McClelland and Phillips conducted a study and analysedthe data from haematology laboratories in the UK for theyears 1990 and 1991. They sent a questionnaire to 400 lab-oratories involved in blood transfusion and only 245 (61%)submitted their reply. The reports included data on deaths,morbidity and near misses. One-third of the laboratoriesreported incidents in which the patient received a wrongunit of blood [8].

Medicolegal assessment of blood transfusion errors—An interdisciplinary challenge

Given a current total incidence of erroneously administered blood transfusions of 1:12,000–1:36,000 (AB0 incompatible 1:38,000), the percentage of lethal outcomes ranges between 2 and 5%; i.e. the sole fact of an erroneous transfusion does not mandatorily result in a causal connection with lethal outcome, which can give rise to problems in the medicolegal assessment. We report on the conception and results of a novel interdisciplinary approach to assess the lethal significance of blood transfusion errors. Besides autopsy, histological investigation and immunohistochemical detection of AB0 incompatible foreign red blood cells in autopsy specimens, transfusion medicine investigations offer the opportunity to assess several immunohaematologic features. We assessed the immunohaematologic gel card (“ microcolumn”) technique for suitability in the forensic assessment of an AB0 incompatible transfusion incident in a septic patient, who had had no history of previous blood transfusions, with lethal outcome. After such an erroneous transfusion had been simulated in vitro, pre-transfusion and cadaver patient blood samples (p.m. interval: 3 days) were analysed. Amongst other things, IgG-loaded erythrocytes were detected in pre- and post-transfusion samples; the presence of irregular antibodies directed against blood group antigens and anti-A or anti-B isoagglutinins, respectively, especially in the pre-transfusion sample was ruled out. Besides the demonstration of AB0 incompatible red blood cells in the cadaver blood sample, blood group incompatibilities other than AB0 were excluded. With regard to the cause of death, in synopsis with autopsy findings and clinical symptoms, the results did not allow for a final discrimination between the impact of the pre-existing septic inflammatory response syndrome and sepsis, respectively, and potential lethal effects of a (haemolytic) transfusion reaction. Besides pre- and post-transfusion compatibility testing in clinical transfusion medicine as required by German National Guidelines, the reported immunohaematologic investigations offer an important supportive tool for the forensic assessment of lethal erroneous transfusions and investigation of blood samples of survivors of transfusion incidents as well. Besides established morphological techniques, they allow for a certain evaluation of the pathophysiological impact of transfusion incidents as well as a diversified assessment of immunohaematologic features beyond the AB0 system.

Hemolytic transfusion reaction: Safeguards for practice

Most hemolytic transfusion reactions result from administration of ABO-incompatible blood. Even a small amount of incompatible blood may initiate a reaction and cause devastating consequences leading to death. Careful monitoring of the anesthetized patient is important in recognizing symptoms of a transfusion reaction so that the reaction may be promptly detected and treatment quickly initiated. Many factors contribute to blood transfusion errors resulting from the misidentification of either the patient or the blood product. Nursing has opportunities to establish policies and procedures, design nursing practices, and educate staff to help avoid blood transfusion errors. © 2002 by American Society of PeriAnesthesia Nurses.

Blood transfusion errors are still on the increase

Blood transfusion errors are still on the increase

Deceptively Low Morbidity from Failure to Practice Safe Blood Transfusion: An Analysis of Serious Blood Transfusion Errors

Deceptively Low Morbidity from Failure to Practice Safe Blood Transfusion: An Analysis of Serious Blood Transfusion Errors