Wrong Blood Research Articles

The immunohematologic and patient safety benefits of a centralized transfusion database

The transfusion medical record is an important tool for providing safe and appropriate blood. However, many patients seek care at more than one hospital and this record is usually not portable. We posited that a centralized transfusion service database (CTS-D) offers benefits through tracking blood types, transfusion requirements, and detecting wrong blood in tube (WBIT). Records held in the CTS-D from 1997 to 2010 were queried to enumerate those seen at more than one hospital versus one hospital only. Transfusion-related attributes were collected including red blood cell (RBC) antibodies, transfusion requirements, and reactions. WBITs detected due to historical ABO typing were tallied. A review of blood orders that required alteration based on requirements held in the CTS-D was completed. There were 724,584 records; 10.9% of patients had been tested or received blood transfusion at more than one hospital. Of the 63,973 records with RBC alloantibodies, a greater proportion of patients were seen at more than one hospital versus one hospital only (7.11% vs. 3.97%, p < 0.005). Of the 97,687 patient records that required special processing, patients seen at one hospital had a lower rate than those at more than one hospital (12.13% vs. 24.59%, p < 0.005). There were 77 WBITs (0.18 WBITs per 1000 patients). An in-depth review of WBITs found an additional 26.3% (5 of 19) were detected because the current and historical ABO types were from two different hospitals within the CTS. The CTS-D provides a universal transfusion record that improves patient safety. As health care systems are enlarged, centralization of the transfusion component of the medical record should be considered.

Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST)

One of the most frequent causes of transfusion-associated morbidity or mortality is the transfusion of the wrong blood to the wrong patient. This problem persists in spite of the incorporation of numerous procedures into the pretransfusion checking process in an effort to improve patient safety. A qualitative study was undertaken to understand this process from the perspective of those who administer blood products and to identify concerns and suggestions to improve safety. Twelve focus group discussions and seven individual interviews were conducted at six hospitals in five countries (n = 72 individuals). Health care professionals from a variety of clinical areas participated. Data analysis identified common themes using the constant comparison method. Five major themes emerged from the analysis: the pretransfusion checking process, training, policy, error, and monitoring. Findings include the following: staff were aware and appreciative of the seriousness of errors and were receptive to continuous monitoring, the focus was on checking the bag label with the paperwork rather than the bag label with the patient at the bedside, training methods varied with most perceived to have minimal effectiveness, and access to policies was challenging and keeping up to date was difficult. Other factors that could contribute to errors included high volume of workload distractions and interruptions and familiarity or lack of familiarity with patients. Multiple factors can contribute to errors during the pretransfusion checking limiting the effectiveness of any individual intervention designed to improve safety. Areas of further research to improve safety of blood administration were identified.

Automatic Electronic System to Human Blood Typing

Abstract Blood typing is a crucial test before a blood transfusion and it can be critical, especially in emergency situations, due to the patient condition. Moreover, blood transfusions based on the universal donor (O-), or on the wrong blood type, may risk the patient's life. For that, in this research the main principles to the development of a miniaturized, low cost, portable and automatic system to human ABO-Rh blood typing and based on a spectrophotometric approach are presented. This system will reduce some limitations of the existing methods to human blood typing.

Operational, Quality, and Risk Management in the Transfusion Service: Lessons Learned

For general health care, the difference between quality and safety has been unclear for measurable patient outcomes. In contrast, in the transfusion service (TS), the relationship between quality and safety has been direct and demonstrable. Case studies are summarized to illustrate the relationship between operations, quality management, and risk management in the TS. In blood availability for elective surgery over 3 audited intervals, the incidence of patients undergoing elective surgery without available crossmatched blood that had been requested was 1:333, 1:328, and 1:225 for pre-quality improvement, post-quality improvement, and subsequent postintervention audit assessment, respectively. In event discovery reports (EDRs) over 2 years, incidence of biologic product deviation reports (Food and Drug Administration reportable) was successfully reduced from 60 biologic product deviation reports (12%) of 507 EDRs in 2009 to 42 (12%) of 336 EDRs in 2010. In wrong blood in tube, 102 specimens were identified (by a change in patient's ABO/Rh) from 176,711 type and screen/cross-match specimens received over a 5-year interval, detected either by previous patient record of ABO/Rh or by a second specimen for blood type confirmation implemented in our TS for the last 3 years. No known cases of "mismatched" red blood cell transfusion have occurred during this interval. There is an inverse relationship between resources/time expended on quality and risk management relative to volumes of operations in the TS. Laboratory-based initiatives that improve patient safety and clinical outcomes need to have resources aligned with the personnel and time required for quality management and risk management.

The New Zealand national haemovigilance programme: the first step is the hardest

Blood transfusion is an important component of modern day medicine. As doctors our first consideration must always be the interests and safety of our patients. Haemovigilance programmes collect and analyse data on untoward events associated with transfusion. The information collated should be shared with health professionals who prescribe and administer blood products so that they can continue to deliver the good without unintended negative consequences.The European Directorate for the Quality of Medicines and Healthcare (EQDM) defines the standards for haemovigilance and acknowledges that it is a shared responsibility of the professionals in the field and the competent national authorities for blood safety. It includes the surveillance of donor‐related events, epidemiological assessment of infections in donors, full traceability of blood components, device defects and reporting of post‐transfusion infections.Implementation of a national haemovigilance system is a complex task and usually takes months of planning. Apart from the multiple resources it requires, a number of issues need to be considered: what is to be reported, how will it be reported and who will do the reporting. In addition, information and training needs to be provided to the key stakeholders.In order for a haemovigilance programme to be effective the data need to be collated, analysed and relayed back to the hospitals. Comprehensive annual haemovigilance reports that are readily accessible can include recommendations to promote strategies to reduce transfusion‐related risks.In New Zealand the National Haemovigilance Programme was established in 2005. The population of New Zealand is 4·1 million. Reporting is voluntary and usually mediated via the hospital blood banks. The larger hospitals have Transfusion Nurse Specialists (TNSs) who provide education and assist with reporting adverse events. New Zealand is a country member of the Internal Haemovigilance Network (IHN) and utilizes the definitions of reporting categories agreed upon by the IHN. The majority of reports involve reactions that are mild. The overall rate of an adverse event is approximately 1 in 300 units transfused. Platelet concentrates are more frequently associated with reactions compared with other blood components and reactions are predominantly of the allergic type.The Haemovigilance Programme has demonstrated a reduction in the reported rate of transfusion‐related acute lung injury (TRALI) since the introduction of male donor fresh frozen plasma (FFP) 3 years ago. The programme has also identified that bacterial contamination of blood components, incorrect blood component transfused (IBCT), wrong blood in tube (WBIT) and acute haemolytic transfusion reactions due to transfusion of passive haemolysin are risks that require further attention.Complications associated with blood donation are also included in the annual haemovigilance reports. Vasovagal reactions are the most frequently occurring donation‐associated event and are higher in donors under the age of 20 years.Ongoing surveillance and review of untoward events associated with transfusion is vital so that we can continue to minimize risks related to blood products.

Laboratory characteristics and clinical utility of post-operative cell salvage: washed or unwashed blood transfusion?

The development of complex surgical procedures for the treatment of a number of diseases has increased the demand for allogeneic blood. In hospitals, up to 50% of transfused blood units are used in the surgical setting and up to 60% of all transfusions are given to patients over 65 years old, an age group of patients who are excluded from altruistic blood donation in some countries1,2. The demand for allogeneic blood often exceeds the supply. The safety of allogeneic blood transfusion (ABT) in developed countries has improved dramatically, especially as a result of more restrictive criteria for donor selection and increased analytical screening of donated blood which have led to a decrease in the rate of transfusion-transmitted infections. However, “clerical mistakes” or administration of “wrong blood” are still too frequent (1/15,000-20,000 units)3,4. Liberal transfusion protocols (pre-transfusion haemoglobin [Hb] concentration > 9-10 g/dL) should, therefore, be avoided to further reduce the risk of infection and other complications such as incompatible haemolytic reactions, Graft-versus-Host Disease, metabolic disorders, Transfusion-Related Acute Lung Injury, and transfusion related immuno-modulation3,4. As for immuno-modulation, the results of three extensive studies involving more than 22,000 patients undergoing orthopaedic surgery strongly suggest that peri-operative ABT is associated with an increase in the risk of post-operative infection5–7. Overall concerns about the adverse effects of ABT have prompted the review of transfusion practices and the search for transfusion alternatives, such as pre-operative autologous blood donation, haemodilution, peri-operative cell salvage, recombinant human erythropoietin (rHuEPO) and iron, or anti-fibrinolytic administration8. The ultimate objective is to minimise exposure to ABT and, therefore, ABT-associated risks. The main objective of this review is to provide updated evidence on the quality, safety and efficacy of postoperatively salvaged shed blood (PSB) after major surgery. However, the results of a systematic review indicate that reinfusion of unwashed filtered PSB after cardiac surgery produces only a marginal benefit9 and can also cause significant adverse effects, so its use is not recommended10. We, therefore, shall focus mainly on the use of PSB in orthopaedic surgery, especially lower limb joint replacement.

‘Wrong blood in tube’: solutions for a persistent problem

This study was performed to determine the incidence of 'wrong blood in tube' (WBIT)-type errors at our institution during the past 5 years, to analyse their root cause and to evaluate the efficacy of preventive measures that have been implemented since 2006. All reports of mislabelled and miscollected specimens detected between January 2005 and December 2009 were reviewed. Of these, WBIT-type errors were further analysed as they represent a major risk for mistransfusion. Between 2005 and 2009, 59,373 type and screens were performed at our institution and a total of 26 major errors (WBIT) were identified. Of the errors, eight were detected by discrepant typing results (in comparison with historic blood type), six were discovered by the clinical service and 12 were identified in the blood bank by other means. Our estimated 'raw' WBIT rate (1 in 2283 samples) is comparable to that (1:2262) in the published literature. Since 2006, our nursing policy mandates that 'all type, screen and cross will have two witnesses to the correct ID of the patient and labeling is done at the bedside at the time of the draw.' This has reduced (from 11 in 2006 to 5 in 2007), but did not eliminate, our WBIT problem that persisted into 2008 and 2009 (three and seven incidents, respectively). Since 2009, we also require a second, independently drawn sample in previously un-typed patients who are likely to be transfused. We conclude that WBITs continue to represent a leading cause of potential mistransfusions at our institution. Changes in nursing (two witnesses to correct ID) and/or blood bank policy (check-type with a second specimen) may reduce, but not eliminate, this persistent problem. Clearly, additional safety measures are required to prevent WBIT-type errors.

Quality management in the transfusion service: case studies in process improvement

Laboratory-based quality improvement (QI) initiatives can improve clinical outcomes and patient safety. We present three cases of QI that impact processes from the transfusion service (TS) laboratory to the patient's bedside. Case 1 was event discovery reporting (EDR). We were able to reduce our biologic product deviation reports from 41 (17%) of 238 EDRs to only 19 (7%) of 272 (p < 0.01) EDRs after implementation of a QI workflow process. Case 2 was antibody evaluation before elective surgery. We implemented process improvement strategies: 1) surgical safety checklist with confirmation of type-and-screen completion and antibody evaluation before patients can proceed to surgery; 2) specimen retention policy of 30 days to allow advance testing; and 3) daily review to identify specimens needed on day of surgery. After intervention, only 7 (0.3%) of 2298 patients required antibody evaluation on day of surgery, compared to 65 (0.75%) of 8656 patients (p < 0.01) before intervention. Case 3 was wrong blood in tube (WBIT). We have a two-specimen requirement for blood type verification before transfusion. To determine whether trauma patients should be exempted, we reviewed WBIT errors. Six WBIT errors were from the emergency department (an error rate of 1:400) and nine WBIT specimens were institution-wide. Three patients were transfused after correction of the WBIT error. Based on this analysis, our institution agreed that no clinical units shall be exempted from our policy. Successful QI in the TS improves processes that promote efficiency, effectiveness, and patient safety.

Blood Bank Safety Practices: Mislabeled Samples and Wrong Blood in Tube—A Q-Probes Analysis of 122 Clinical Laboratories

Although a rare occurrence, ABO incompatible transfusions can cause patient morbidity and mortality. Up to 20% of all mistransfusions are traced to patient misidentification and/or sample mislabeling errors that occur before a sample arrives in the laboratory. Laboratories play a significant role in preventing mistransfusion by identifying wrong blood in tube and rejecting mislabeled samples. To determine the rates of mislabeled samples and wrong blood in tube for samples submitted for ABO typing and to survey patient identification and sample labeling practices and sample acceptance policies for ABO typing samples across a variety of US institutions. One hundred twenty-two institutions prospectively reviewed inpatient and outpatient samples submitted for ABO typing for 30 days. Labeling error rates were calculated for each participant and tested for associations with institutional demographic and practice variable information. Wrong-blood-in-tube rates were calculated for the 30-day period and for a retrospective 12-month period. A concurrent survey collected institution-specific sample labeling requirements and institutional policies regarding the fate of mislabeled samples. For all institutions combined, the aggregate mislabeled sample rate was 1.12%. The annual and 30-day wrong-blood-in-tube aggregate rates were both 0.04%. Patient first name, last name, and unique identification number were required on the sample by more than 90% of participating institutions; however, other requirements varied more widely. The rates of mislabeled samples and wrong blood in tube for US participants in this study were comparable to those reported for most European countries. The survey of patient identification and sample labeling practices and sample acceptance policies for ABO typing samples revealed both practice uniformity and variability as well as significant opportunity for improvement.

When and why is blood crossmatched?

This study was undertaken to provide data relating to the timing of laboratory crossmatch procedures, and the source of requests for out of hours crossmatch, to support interpretation of error reports originating in the transfusion laboratory, received by the Serious Hazards of Transfusion haemovigilance scheme. Data on the timing, origin and urgency of all crossmatch requests were collected in 34 hospitals in northern England over a 7-day period in 2008. Additional data on clinical urgency were collected on crossmatches that were performed out of hours. Data were obtained on 2423 crossmatches, including 610 (25.2%) performed outside core hours. 30.3% of out of hours crossmatch requests were for transfusions that were set up outside 4 h of completion of the crossmatch. 2008 Serious Hazards of Transfusion data showed that 29/39 (74%) of laboratory errors resulting in 'wrong blood' occurred out of hours whilst our audit shows that only 25% of crossmatch requests are made in that time period, suggesting that crossmatching performed outside core hours carries increased risks. The reason for increased risk of error needs further research, but 25 laboratories had only one member of staff working out of hours, often combining blood transfusion, haematology and coagulation work. A total of 25% of out of hours requests were not clinically urgent. Hospitals should develop policies to define indications for out of hours transfusion testing, empower laboratory staff to challenge inappropriate requests and ensure that staffing and expertise is appropriate for the workload at all times.

Detecting 'wrong blood in tube' errors: Evaluation of a Bayesian network approach.

In an effort to address the problem of laboratory errors, we develop and evaluate a method to detect mismatched specimens from nationally collected blood laboratory data in two experiments. In Experiments 1 and 2 using blood labs from National Health and Nutrition Examination Survey (NHANES) and values derived from the Diabetes Prevention Program (DPP) respectively, a proportion of glucose and HbA1c specimens were randomly mismatched. A Bayesian network that encoded probabilistic relationships among analytes was used to predict mismatches. In Experiment 1 the performance of the network was compared against existing error detection software. In Experiment 2 the network was compared against 11 human experts recruited from the American Academy of Clinical Chemists. Results were compared via area under the receiver-operator characteristic curves (AUCs) and with agreement statistics. In Experiment 1 the network was most predictive of mismatches that produced clinically significant discrepancies between true and mismatched scores ((AUC of 0.87 (±0.04) for HbA1c and 0.83 (±0.02) for glucose), performed well in identifying errors among those self-reporting diabetes (N=329) (AUC=0.79 (±0.02)) and performed significantly better than the established approach it was tested against (in all cases p<.0.05). In Experiment 2 it performed better (and in no case worse) than 7 of the 11 human experts. Average percent agreement was 0.79 and Kappa (κ) was 0.59, between experts and the Bayesian network. Bayesian network can accurately identify mismatched specimens. The algorithm is best at identifying mismatches that result in a clinically significant magnitude of error.

CDC Launches Surveillance System to Improve Blood Transfusion Safety

A SYSTEM LAUNCHED IN FEBRUary by the US Centers for Disease Control and Prevention (CDC) will help track adverse events associated with blood transfusion and give hospitals and public health officials tools they can use to help prevent such events in the future. The Hemovigilance Module is the newest component of the CDC’s National Healthcare Safety Network, a confidential and voluntary online surveillance system that the agency uses to track infections associated with health care. The module was created by the CDC in collaboration with AABB (formerly the American Association of Blood Banks), an organization that represents institutions and professionals involved in blood transfusion and transplantation. “Clinicians need to understand that although blood transfusion is very safe, there are adverse events,” said Matthew J. Kuehnert, MD, director of the CDC’s Office of Blood, Organ, and Other Tissue Safety. Kuehnert explained that the system will track events in which patients develop adverse reactions to transfusions—for example, if a patient receives the wrong blood type, has an allergic reaction, or contracts an infection. Moreover, the system will also track incidents in which procedures intended to ensure patient safety do not work properly and lead to patient harm or near misses. For example, if a physician orders one blood type, but the wrong blood type is delivered to the patient’s room, that would be considered such an incident. Often such a mix-up would be caught by redundant safety protocols before the patient receives the wrong type of blood; however, such problems increase the risk of poor outcomes. The system will for the first time provide national data on transfusion safety in the United States. Previously, surveillance of adverse events has been fragmented. Barbee Whitaker, PhD, director

Patients' positive identification systems.

Blood safety must be maintained throughout the whole transfusion chain to prevent the transfusion of incorrect blood components. The estimated risk of an incorrect transfusion is in the order of 1 per 10,000 units of blood. Although several kinds of errors contribute to "wrong blood" events, 70% of errors occur in clinical areas with the most common being due to failure of the pre-transfusion bedside checking procedure. Several methods are available to reduce such errors. The I-TRAC Plus system by Immucor consists of an identification bracelet which is a bar-coded wristband and a handheld portable computer that identifies patients and blood bags by a scanner and prints the information through a portable printer. The labels attached on the blood order forms and on the sample tubes are read and recorded in the blood bank's informatics system (EmoNet INSIEL). Labels showing the bar-code of the assigned number, which includes the ID number of the patient, the ID number of the unit and a code identifying the kind of product and use (allogeneic or autologous), are generated and applied to the blood components. The transfusions are administered after checking the unit and the patient's wristband using the scanner of a portable PC. In 5 years a total of 71,400 units of blood components were transfused to 15,430 patients using the I-TRAC Plus system. The system prevented 12 cases of mis-identification of patients (5 in 2003, 0 in 2004, 1 in 2005, 1 in 2006 and 5 in 2007). In 2003 we introduced the use of a bar-code matching system between a patient's wristband and the blood bag to avoid mistakes at the bedside. In 5 years the system provided benefits by avoiding errors in the identification of patients, thus preventing "wrong blood" transfusions.

UK Transfusion Laboratory Collaborative: Recommended minimum standards for hospital transfusion laboratories

The Serious Hazards of Transfusion (SHOT) Adverse Incident Reporting Scheme (SHOT Annual Reports, 1996–2008) has consistently reported that 30–40% of ‘wrong blood’ event errors are due to errors originating in the hospital blood transfusion laboratory with a disproportionate number occurring outside ‘core hours'. Evidence collated from two national surveys (Summary of Two National Surveys of UK Transfusion Laboratories, http://www.ibms.org/index.cfm?method=science.transfusion_science) of UK Transfusion Laboratories has formed the basis for the following recommendations aimed at reducing blood transfusion laboratory errors by 50% by 30 September 2012. The collaborative recommendations are intended to encourage effective and appropriate use of technology and staff in hospital transfusion laboratories within the framework of current legislative requirements. These recommendations will help hospitals and trusts in achieving the minimum standards of proficiency and practice set by The Health Professions Council (HPC) (HPC Standards of Proficiency, 2004) and as required by the UK Blood Safety and Quality Regulations (as amended) (BSQR 2005). The collaborative recognises that not all existing hospital transfusion laboratory structures may currently meet all of these recommendations. However, hospitals and trusts will be expected to work towards these recommendations if transfusion services are reconfigured, as new posts are established or new staff members are appointed. It is recommended that appropriate staff currently in post who do not hold one of the qualifications listed in recommendation 3.1 must demonstrate equivalence to the learning outcomes of an Institute of Biomedical Science (IBMS) Higher Specialist Diploma in Transfusion Science or an IBMS accredited MSc in Transfusion and Transplantation to meet recommendations 3.4 and 3.6 below. It is recommended that appropriate staff currently in post who do not hold one of the qualifications listed in recommendation 3.2 must have their competency assessed against the learning outcomes of one of these qualifications before undertaking lone-working to meet recommendations 3.4 and 3.6 below.

Strict Adherence to a Blood Bank Specimen Labeling Policy by All Clinical Laboratories Significantly Reduces the Incidence of “Wrong Blood in Tube”

Phlebotomy errors leading to incompatible transfusions are a leading cause of transfusion-related morbidity and mortality. Our institution's specimen-labeling policy requires the collection date, 2 unique patient identifiers, and the ability to identify the phlebotomist. This policy, however, was initially strictly enforced only by the blood bank. In fiscal year 2005, following an educational campaign on proper specimen labeling, all clinical laboratories began strictly adhering to the specimen-labeling policy. Compared with the preceding 4 years, in the 3 years following policy implementation, the incidence of wrong blood in tube (WBIT) and mislabeled specimens detected by the blood bank decreased by 73.5% (0.034% to 0.009%; P < or = .0001) and by 84.6% (0.026% to 0.004%; P < or = .0001), respectively. During a short period, a simple, low-cost educational initiative and policy change can lead to statistically significant decreases in WBIT and mislabeled specimens received by the blood bank.

Pre-registration adult nurses’ knowledge of safe transfusion practice: Results of a 12 month follow-up study

This research project ascertained student nurses' knowledge retention of safe transfusion practice following a standardised teaching and learning programme (produced by the Scottish National Blood Transfusion Service, United Kingdom (UK)) within a School of Nursing in Scotland, UK. Several studies including the Serious Hazard of Transfusion (SHOT) annual reports demonstrated that there are risks to the patient in receiving blood components: receiving the wrong blood was the most common risk associated with blood transfusion (Ottewill, 2003; SHOT, 2007). This evaluative study used a questionnaire to assess the level of knowledge students (n=118) attained on the day of the session, 4-6 months and 11-12 months following the session. The study provided an insight into the effectiveness of a standardised teaching approach and highlighted areas for review in light of incorrect answers elicited. Despite all receiving the Standardised Programme, there was a wide range of initial overall scores achieved. The study demonstrated, within the small sample completing at all 3 time points, that there is clear degradation of knowledge during the study period. The influence of experience on knowledge retention appears to have a positive effect at 6 months but no appreciable effect at 12 months. These outcomes merit further, more robust and multi centre investigation to identify if there is replication of results.

Blood transfusion for the treatment of acute anaemia in inflammatory bowel disease and other digestive diseases

Allogeneic blood transfusion (ABT) is frequently used as the first therapeutic option for the treatment of acute anaemia in patients with inflammatory bowel disease (IBD), especially when it developed due to gastrointestinal or perioperative blood loss, but is not risk-free. Adverse effects of ABT include, but are not limited to, acute hemolytic reaction (wrong blood or wrong patient), febrile non-hemolytic transfusional reaction, bacterial contamination, transfusion-related acute lung injury, transfusion associated circulatory overload, transfusion-related immuno-modulation, and transmission of almost all infectious diseases (bacteria, virus, protozoa and prion), which might result in increased risk of morbidity and mortality. Unfortunately, the main physiological goal of ABT, i.e. to increase oxygen consumption by the hypoxic tissues, has not been well documented. In contrast, the ABT is usually misused only to increase the haemoglobin level within a fixed protocol [mostly two by two packed red blood cell (PRC) units] independently of the patient's tolerance to normovolemic anaemia or his clinical response to the transfusion of PRC units according to a "one-by-one" administration schedule. Evidence-based clinical guidelines may promote best transfusion practices by implementing restrictive transfusion protocols, thus reducing variability and minimizing the avoidable risks of transfusion, and the use of autologous blood and pharmacologic alternatives. In this regard, preoperative autologous blood donation (PABD) consistently diminished the frequency of ABT, although its contribution to ABT avoidance is reduced when performed under a transfusion protocol. In addition, interpretation of utility of PABD in surgical IBD patients is hampered by scarcity of published data. However, the role of autologous red blood cells as drug carriers is promising. Finally, it must be stressed that a combination of methods used within well-constructed protocols will offer better prospects for blood conservation in selected IBD patients undergoing elective surgery.

Enhanced detection of blood bank sample collection errors with a centralized patient database

Pittsburgh's Centralized Transfusion Service (CTS) provides transfusion support to 16 hospitals and features an electronic database that contains patient transfusion and serologic histories. This database can be accessed from any hospital in the system. A major cause of ABO-incompatible transfusions is the "wrong blood in tube" (WBIT) phenomenon, that is, the sample is not from the recipient identified on the label. We hypothesized that having access to patient historical ABO types from anywhere in the CTS system can identify WBIT errors and prevent mistransfusions. The transfusion committee records of the 16 CTS hospitals from March 2005 to September 2007 were reviewed for major collection errors, that is, the current ABO type differed from the historical type in the database. The patient's historical ABO type, the discrepant type, and the hospital(s) where these samples were collected were recorded. In 6 of 16 major collection errors for which complete information was available, the current and historical ABO types were obtained from different hospitals within the CTS system. In 3 cases, selection of ABO type-specific blood based on the current sample would have led to an ABO-compatible transfusion (e.g., correct type A, current type O). In the other 3 cases, an ABO-incompatible transfusion would have resulted (e.g., correct type O, current type A). Access to a centralized patient database detected 38 percent more ABO typing errors and prevented six mistransfusions, which would not have been prevented at a single institution. Centralization of patient transfusion data should be encouraged.

Immunological complications of blood transfusion

SUMMARYIn the developed world, most of the reported complications of transfusion have an immunological basis. Although the media and the public are worried about the infectious risks of transfusion, hemovigilance reports show that antigen–antibody reactions are responsible for the vast majority of acute and delayed transfusion reactions. Among the immediate complications of transfusion, the most common and serious are intravascular hemolytic transfusion reactions because of ABO incompatibility caused by giving the wrong blood to a patient (e.g. group A blood to a group O recipient). Fortunately, the vast majority of ABO‐incompatible transfusions do not lead to major morbidity or mortality. Another important cause of severe immediate transfusion reactions is transfusion‐related acute lung injury (TRALI), caused by white cell antibodies in donor plasma. The most common, although not severe, acute tansfusion reactions are urticaria and febrile, nonhemolytic, mostly preventable by leukodepletion and leukoreduction. Delayed transfusion reactions are: (i) hemolytic, caused by anamestic responses to red cell antigens, causing hemolysis days after the transfusion; (ii) post‐transfusion purpura, caused by an anmnestic response to platelet antigens; (iii) graft‐versus‐host disease, caused by engrafted donor lymphocyte reacting against the recipient; and (iv) immunological refractoriness to platelet transfusions, caused mostly by human leukocyte antigen antibodies destroying transfused platelets. The diagnosis of most of these complications can now be made by immunohematologists, with the aid of specialist reference laboratories, thus enabling prompt therapy as required.

Promoting safe transfusion practice: right blood, right patient, right time

Despite an array of initiatives designed to support the delivery of safe and appropriate transfusion practice, incidences of patients receiving the wrong blood continue to be reported. Nurses play a key role in delivering safe and appropriate transfusion care and have a responsibility to support national initiatives, such as the NHS Better Blood Transfusion programme of action and the National Patient Safety Agency Safer Practice Notice 14, Right Patient, Right Blood. This article examines factors, which impact on the successful implementation of a programme aimed at promoting best transfusion practice, such as organizational support, leadership, education and competency assessment, and the role of audit and feedback. By championing the systematic assessment of transfusion procedures, the implementation of education and guidelines and the use of innovative approaches, such as care bundles, we can ensure that nurses have the appropriate knowledge, skills and understanding to provide the highest standards of transfusion care to our patients.