Blood transfusions error

 Introduction:
Blood transfusion is a lifesaving process which is composed of receiving blood or blood products into
one’s circulation intravenously. Blood has several components, including:

 Red cells carry oxygen and help remove waste products

 White cells help your body fight infections

 Plasma is the liquid part of your blood

 Platelets help your blood clot properly

According to the American Red Cross, there are four common types of blood transfusions:
 Red blood cell transfusions: A person may receive a red blood cell transfusion if they
have experienced blood loss, if they have anemia (such as iron deficiency anemia), or if
they have a blood disorder.
 Platelet transfusions: A platelet transfusion can help those who have lower platelet
counts, such as from chemotherapy or a platelet disorder.
 Plasma transfusions: Plasma contains proteins important for health. A person may
receive a plasma transfusion if they have experienced severe burns, infections, or liver
failure.
 Whole blood transfusion: A person may receive a whole blood transfusion if they have
experienced a severe traumatic hemorrhage and require red blood cells, white blood cells,
and platelets.
Blood transfusion process involves two procedures that are:
1- Collection of blood from donor
2- Administration of blood to the recipient
Indications of blood transfusion :
 To restore the blood volume due to sudden loss of blood because of hemorrhage
 To raise the Hb levels in cases of severe anemia
 To treat deficiencies of plasma protein, clotting factors or hemophilic globulin …etc
 To provide antibodies to those people who are sick and have low immunity
 To replace the blood with hemolytic agent with fresh blood
 To improve leukocytes counts in blood as in agranulocytosis
  To combat infection in leucopenia

Transfusion is often unnecessary for the following reasons.

- 1 The need for transfusion can often be avoided or minimized by the prevention or early
diagnosis
- and treatment of anaemia and conditions that cause anaemia.

- 2 Blood is often unnecessarily given to raise a patient’s haemoglobin level before surgery
or to allow earlier discharge from hospital. These are rarely valid reasons for transfusion.

- 3 Transfusions of whole blood, red cells or plasma are often givenwhen other treatments,
such as the infusion of normal salineor other intravenous replacement fluids would be
safer, less
- expensive and equally effective for the treatment of acute blood loss.

- 4 Patients’ transfusion requirements can often be minimized bygood anaesthetic and

surgical management.

- 5 If blood is given when it is not needed, the patient receives no benefit and is exposed to
unnecessary risk.

- 6 Blood is an expensive, scarce resource. Unnecessary transfusions may cause a shortage

of blood products for patients in real need.

Risks of blood transfusion:

The transfusion of blood is an allogeneic transplant and, as such, is a medical procedure that
carries intrinsic, irremovable components of risk:
 first and foremost, the biological risk, related to the genetic difference of the blood
transfused;
 the risk of transmitting diseases
 an intrinsic therapeutic risk, related to possible adverse events deriving from an
interaction between the medical intervention and the individual’s organic equilibrium;
 the risk of medical errors due to a wrong decision;
 the risk of technical and/or administrative errors due to the lack or mistaken application
of procedural rules.
Although blood transfusion is a lifesaving treatment but it requires critical attention to processes
and details in each step. If standard guidelines are not followed accurately, grievous errors can
lead to sentinel events. So, Transfusion safety must be taken into consideration and it involves a
series of complex events starting from ordering of blood or blood products, appropriate
specimen collection, compatibility testing (cross matching), and product issue from the blood
bank, to blood administration at the patient’s bedside, monitoring of the transfused patient,
managing of adverse reactions, and documentation of transfusion adverse events and outcomes.
Any indulgence in one of these tips leads to an error.
https://www.aabb.org/news-resources/news/article/2021/08/04/2020-shot-report-details-
transfusion-related-events-in-u.k
https://onlinelibrary.wiley.com/doi/10.1111/bjh.12547
https://academic.oup.com/labmed/article/32/4/205/2504216

The four danger points in the transfusion process have been identified by The Serious
Transfusion Incident Reporting (STIR) system as:
1. the medical decision to transfuse • ‘many doctors are ill informed, outdated or simply
incorrect’ (Dzik 2003).
2. the collection of patient samples • ‘this accounts for between 10-15% of errors’ (Linden,
Wagner et al. 2000).
3. the laboratory where samples are analysed • ‘manual techniques for blood grouping are
inherently unsafe’ (Stainsby, Russell et al. 2005).
4. the bedside administration of blood components • ‘done by humans in a manner little
changed in 50 years’ (Dzik 2003).

Nursing role in blood transfusion and blood transfusion errors:

As we mentioned earlier the process of transfusion consists of five interrelated phases: blood
grouping and cross-matching, patient preparation before blood bag collection, blood pack
collection, pretransfusion initiation of nursing responsibilities, and posttransfusion nursing care
[5]. Four of these phases are relevant to routine nursing practice. The safety and adequate
management of transfusion of blood and blood products, therefore, depends largely on the
knowledge and skills of nurses.
The role of nurses is crucial for proper management of transfusion reactions to achieve
desirable results, for two main reasons: the process of transfusion is dominated by nursing-
related responsibilities, and nurses constitute the last link in the chain of the transfusion process
[9]. Nurses must therefore have acceptable knowledge and competencies in transfusion of blood
and blood products.
https://ir.ucc.edu.gh/xmlui/bitstream/handle/123456789/2947/TETTEH%202015.pdf?
sequence=1&isAllowed=y
https://www.hindawi.com/journals/ah/2021/6739329/

In a process of risk assessment for blood transfusion errors, different periods of potential risk
and different factors can be identified in relation to the various stages of the transfusion
process1:
1. risks of transmissible diseases from the donor (presence of viruses, bacteria, parasites in
the donor’s blood; presence of immunological disorders; presence of neoplastic diseases;
presence of potentially pathogenic foreign substances);
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7120358/#:~:text=Blood%20products
%20transfusion%20can%20cause,transfusion%2Drelated%20immunosuppression
%20predisposing%20to

https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-
transfusion-event
https://patientsafetyj.com/index.php/patientsaf/article/view/blood-transfusion-errors

2. risks related to the collection of the blood (possible bacterial contamination due to
inadequate disinfection of the sampling site; possible administrative-type errors in
unequivocal identification of the donor/exchange of biological samples);
3. risks related to the processing/storage of the blood (non-sterile processing, inappropriate
storage, labelling errors);
4. risks related to the process of biological qualification (pre-analytic, analytic and post-
analytic errors; intrinsic limitations of the methods used: sensitivity/window period);
5. risks related to requests/assignation of the blood (administrative-type errors in identifying
the patient and labelling the samples; medical errors in terms of therapeutic
appropriateness of the transfusion);
6. risks associated with the unequivocal identification of the patient at the time of the
transfusion;
7. risks from immunological interactions between the recipient and transfused unit due to
donor-related factors (presence of undetectable antibodies against antigens in the
 recipient or the presence of particular genetic profiles predisposing to graft-versus-host
disease reactions) or recipient-related factors (immunosuppression or the presence of
antibodies against antigens on the transfused blood cells);
8. risks related to the patient’s clinical condition (presence of heart failure, presence of
autoimmune diseases).
 Root causes and fishbone diagram:
Patient Identification
- ID labels
- wristband
- chart
- proper verification transfusion
- Lab near miss
- Vague policies / unfollowed
- No standard process
performance/ No standard
operating procedure (SOP)
- Insufficient training and
knowledge
- Inadequate professional
practice
Methods
Root cause
Patient identification
People / staff
People/staff
- Experience & age of HCP
Equipment /
- Communication machine
- Workload tolerance and
Human factors
- Multi-tasking ability - Blood tube familiarity
- Under staffing and shortage - Labelling of blood samples
- Professional practice - Availability of labels
- Team culture - Stocking of blood trolleys
- - Gloves
Blood
transfusion
errors
- Physical environment
- Blood order
- Accessibility
- Blood donation
- Crowdedness
- Blood testing
- Stress and multitasking
- Blood administration
demand
- Patient -------
Environment Material
Fish bone diagram
Explanation
- incorrect ID labels,
- wristband, chart, etc.;
- lack of proper verification before transfusion
- According to the International Ergonomics Society, ergonomics or (the
more commonly known) human factors can be defined as: ‘...a scientific
 discipline concerned with the understanding of interactions among humans
and other elements of a system, and the profession that applies theory,
principles, data and methods to design in order to optimise human well-
being and overall system performance’ (International Ergonomics
Association 2000).
- Put simply, HF deals with factors influencing human performance, such as
physical environments, individual characteristics, and management
systems. It can contribute to describing known WBIT errors and discovering
unidentified ones, as well as expanding our understanding of their
underlying causal factors. HF is necessary in the investigation of errors
surrounding mislabelling and miscollection of blood samples since, in spite
of attempts to reduce WBITs
- Most of blood taking is performed by junior doctors.
- Age of the doctors: older ages decrease the odds of having a near
miss events.
- Poor communication, taking of blood sample not documented in
notes by any member on duty at night.
- misunderstanding between nursing staff.
- Multitasking nurses staff and no defined roles for each nurse.
- High work load.
- Shortage of nursing staff and inadequate training.
- In adequate patient identification is recognized as a root causes for
serious transfusion errors (Murphy and Kay 2004), include in correct
ID band or wrist band or chart of the patient.
- Failure to check patient identity due to similar names of patients.
- Education and training: Majority of emergency department staff have
not received blood training, due to busy workload.
- Inadequate information flow: Information flow is critical in any
healthcare setting, especially within different service areas.
Insufficient information flow happens when necessary information
does not follow the patient when they are transferred to another
facility or discharged from one component or organization to another.
Inadequate information flow can cause the following problems:
- The lack of crucial information when needed to influence prescribing
decisions.
- Lack of appropriate communication of test results.
- Poor coordination of medication orders for transfer of care.
-

Environment  Working condition and environment:

- Busy night shift is causing pressure on working place.
- Multitasking
- Understaffing and Sleep Deprivation
- environment like the ED, with multiple, interdependent components,
numerous interruptions, and very ill patients, results in the potential for
many errors.

Methods - lack of modern and standard procedures.

- lack of proper verification before transfusion.
- Inaccurate verbal instructions, no request forms of blood transfusions.
 - Inadequate documentation of near miss reporting.
- Mislabeling occurred due to taking blood samples from different
patients at the same time.
- Samples was labeled away from the location of blood taking cause
wrong blood in tube incidents.
- Education and training: Majority of emergency department staff have
not received blood training, due to busy workload.
- Limited access to policies related to blood transfusion processes
- Lack of informed consent and consent not noted in patient chart as
required before blood transfusion.
- The lack of a medical center memorandum noting blood component can be
infused up to four hours
- Low-frequency task

 Lab near miss:

- In correct interpretation of ABO and Rhesus blood grouping.
- In correct specimen handling because of the laboratory technologists
were distracted when handling samples.
- Frequent phone calls made by the wards to confirm cross matching
results.
- Urgent requests call from clinicians and pressure from clinicians to
release blood early.
- • Policy on collecting and labeling type/screen not followed
- • Sample not labeled with the patient info at time of collection
- • Two nurses did not verify sample at bedside
- • Type/screen and ABO/Rh compatibility performed together
- • Type/screen label format varies based on the printer location

Material  Blood samples:

- Wrong blood samples in tube : received the wrong blood type
regarding platelet, red blood cell and plasma.
- ‘Wrong Blood in Tube’ (WBIT) errors are those that occur where patient
identification information (label and request form) belong to one patient but
the blood in the tube belongs to another patient (Dzik, Corwin et al. 2003).
WBIT errors most commonly occur at blood sample collection and are
estimated to affect approximately 1 in 2000 samples (Gonzalez-Porras,
Graciani et al. 2008). Mislabelling tubes occurs more often, affecting, on
average, 1 in 40 samples (Murphy and Kay 2004). The most severe result of
WBIT is a patient receiving a transfusion of the wrong type of blood
(incompatible blood component transfused - IBCT) which can result in death.
Therefore, in spite of their low frequency, WBITs can have catastrophic
consequences. ‘Silent WBITs’, which occur when a patient is transfused, by
chance, with blood of a matching type to their own in spite of a WBIT error
at sample collection, remain hidden in the system. Rates of silent WBITs are
unknown
- Delayed orders and not followed.
- No cross match completed before blood given to patients.
- Blood sample is not tested for diseases ( contaminated blood )
 Blood orders :
 - • Massive blood transfusion (MBT) is a low-frequency, high-risk
- event with unclear accessibility to decision making support
- • No process for ordering blood or resource organization for
- off-tour hours
- • No standard communication process for staff and leadership
- support

Figure 1. Number of Root Causes Linked to Each RCA Event Type Multiple root causes were found within each RCA event
type: patient identification, wrong blood, blood orders, blood labels, consent, transfusion reactions, and crossmatch.
The crossover of these root causes is shown here for each RCA event type.

https://uknowledge.uky.edu/cgi/viewcontent.cgi?article=1173&context=sbcoa_facpub
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053256/
https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1537-2995.2010.02943.x

According to the problem (blood transfusion errors) we discussed it in the introduction,

there are many options that we can use it to solve this problem or even reduce the incidence
of it, it includes:
.adequate training of laboratory technicians, and providing proper transfusion education -1
encouraging compliance to guidelines and training in clinical and laboratory areas to minimize the risk of -2
mistransfusion should be considered
adequate the nurses formal training or an ongoing formal professional development session on blood -3
transfusion
The Blood Transfusion Unit needs to develop simplified standard operating procedures based on the clinical -4
.blood transfusion policy to be posted on clinical areas where blood transfusion is carried out
having an error reporting system in hospitals to highlight human and system failures associated with -5
transfusion that may otherwise go unnoticed. Areas can be identified where resources need to be targeted to
improve patient safety
Develop a new position, Transfusion Safety Officer (TSO), to identify, resolve and monitor regulatory -6.
.weaknesses that lead to the practice of unsafe blood transfusions
Barcode technology : placing the unit of blood in a locked plastic bag, which can only be opened with a -7
code marked on the patient’s wristband and the crossmatch

8- Use the simulation to train transfusion providers and how to respond to emergencies .
The hospital system is implementing a medium term plan called “Code of Crimson” to facilitate rapid -9
availability of blood products when hemodynamic instability occurs in the patient ,among other indications
Develop a new job position recognized as transfusion practitioner as an important link in the -10
.multidisciplinary team, supporting efforts at institutional and national levels to reduce transfusion risks

/https://www.hindawi.com/journals/ah/2021/6739329

https://www.sciencedirect.com/science/article/abs/pii/S0887796303000178

https://onlinelibrary.wiley.com/doi/full/10.1111/j.1423-0410.2010.01366.x

https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1537-2995.2003.00428.x

https://onlinelibrary.wiley.com/doi/epdf/10.1111/tme.12526

https://www.intechopen.com/chapters/62644
Selected option to be analyzed:
1.adequate training of laboratory technicians, and providing proper transfusion education.

2. adequate the nurses formal training or an ongoing formal professional development session on blood transfusion.

3. having an error reporting system in hospitals to highlight human and system failures associated with transfusion that
may otherwise go unnoticed. Areas can be identified where resources need to be targeted to improve patient safety.

4. Barcode technology: placing the unit of blood in a locked plastic bag, which can only be opened with a code marked
on the patient’s wristband and the crossmatch

Alternatives Financial Important Time Applicable Decision

effect
1. adequate training of laboratory ++++ ++++ +++ ++++ 15
technicians, and providing proper
transfusion education
2.adequate the nurses formal ++++ ++++ ++++ ++++ 16
training or an ongoing formal
professional development session
on blood transfusion
3.having an error reporting system +++ ++++ ++ +++ 12
in hospitals to highlight human and
system failures associated with
transfusion that may otherwise go
unnoticed. Areas can be identified
where resources need to be
targeted to improve patient safety
4.Barcode technology: placing the ++ ++++ ++ ++ 10
unit of blood in a locked plastic bag,
which can only be opened with a
code marked on the patient’s
wristband and the crossmatch

Evaluating the Knowledge and Practices of Nurses and Paramedics in Blood Transfusion Services – A survey in the states
of Tamil Nadu and Pondicherry, India - PMC (nih.gov)

https://link.springer.com/article/10.1186/s12913-017-2380-3

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5850694/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613265/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613265/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6432811/

https://www.sciencedirect.com/science/article/pii/S1473050220300185

https://www.koreascience.or.kr/article/JAKO201518050733457.page

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613265/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5850694/

https://link.springer.com/article/10.1186/s12913-017-2380-3
Recommendations

 Professional practice:
Strategies must be in place to ensure labelling and patient ID is always possible at the bedside to combat
a culture in the ED that allows normalisation of the deviant practice of labelling blood samples away
from the bedside.
- Attaching the labels to the patient (strong) – e.g. a barcode scanner for the wristband with a handheld
printer.
- Attaching the labels to the bed (intermediate) – e.g. having a place attached to the bed where spare
labels were available and ensuring that there was a pen which could write on tubes and that the tubes
have a matt surface).
- Attaching the labels to the cubicle (weak) – e.g. having a physical tray to store records for individual
patients which are not easily confused between cubicles.
 Training:
- Junior doctors need more formal education, feedback and support, alongside opportunities to gain
more experience. Ideally this should be given in scenario-based training rather than isolated skills-based
training which is used at present. This will ensure that it covers the distractions and practical issues
surrounding phlebotomy. This is a weak intervention.
- Senior leadership support is required to help raise the profile of risks associated with phlebotomy.
Further work needs to be done to determine innovative ways to increase awareness and application of
proper procedure in blood taking and how to support a program where “champions” for each
department are nominated and can drive improvements.
- Mandatory cannulation competency for all clinical staff is required. Alternatively, protocols must
address tasksharing, especially for patient ID.
 Teamwork:
- . Teams must be established with appropriate supervision of inexperienced team members. The issue of
adequate senior staff supervision is particularly marked in the assessment bay area and in medical
groups, since competing priorities limit this supervision for junior staff, especially for junior doctors.
Further work may include exploring mentoring programs that allocate new interns to certain key
members of senior staff who are responsible for particular areas of practice, i.e. there is one who deals
with blood collection and is a team resource.
 Interaction with the Pathology Laboratory:
- Formal protocols should be developed to feedback problems with samples to ensure that clear
understanding of why samples are rejected reaches the relevant clinical staff. Further work may include
the development of a checklist form which ward clerks must fill out to deliver to clinical staff. This is an
intermediate level strategy.
- Orientation visits of clinical staff to the pathology laboratory and vice versa to improve understanding of
the other group’s role and requirements. Further work would include how best to design and evaluate
these, when and how often to carry them out and how to ensure the majority of staff is included. This is
also an intermediate level strategy
 Request forms:
- In the ED, protocols should allow for standing orders or for nurses to submit blood orders for patients
fitting certain criteria. This is an intermediate strategy and further work is needed to specify the patient
conditions and associated blood tests to be included.
 Feedback:
- Comprehensive feedback is necessary to ensure staff learn from errors and understand risks.
Supervising staff should also be involved in the feedback process for both medical and nursing staff. This
is again intermediate level.
- Further work surrounding best methods of delivering and presenting information on errors, in order to
facilitate individual and unit learning, would help to enable the development of stronger strategies to
support error feedback.
 Patient Identification:
- Further work is needed to determine the level of knowledge of the correct methods of patient
identification in the different staff groups, as some staff are already aware of the protocol but do or
cannot follow it, for a number of reasons. This is an intermediate strategy.
- Increase education for staff with reduced knowledge about risks and consequences of failing to carry
out positive patient ID. Include clarification that the purpose of signatures on blood samples and forms
is to directly verify identity and is a vital part of the ID process. This education should be incorporated
into current scenario based training as environmental and patient factors influence adherence to
protocols. Education is a weak level intervention for changing current behaviour.
- A stronger strategy may be to involve patients in their own safety and to provide information direct to
them regarding the need for repeated positive identification (i.e. encouraging them to demand proper
process for their own safety). A poster campaign in waiting rooms might include punchy messages such
as “Would you let your bank access your account without proper ID?” which sought to make patients
uncomfortable if their identity was not checked as part of blood collection and labelling processes.