Transfusion Error and Near Misses

CME for House Officers and Paramedics in HKL

Prepared by :Blood transfusion team subcommittee

HKL as part of QA/QI project 2011

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Transfusion Error and Near Misses…How to Avoid in Clinical

Setting

Introduction

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Definition of Transfusion Error : - ABO Incompatibility

Definition of near misses :Any error which if undetected could result in the determination of a wrong blood group or transfusion of an incorrect component but was recognized before transfusion took place.

The rationale behind the issue…

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Why is it important to be highlighted now? Answer : Data from HKL has shown an

alarming rise in transfusion error and near misses recently

In 2009 : 26 cases – 9(34.6%) sampling/labeling error!

In 2010 : 36 cases – 15(41.2%)sampling/labeling error!

In 2011 : 23 cases in the first half of the year!

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Cont..

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~ 69% of cases were caused by HUMAN ERROR!

Example of errors include :i) Blood taking / samplingii) Handling of sampleiii) Lab testingiv) Blood retrieval from fridgev) Pt’s ID and bedside checking

before transfusion

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Most errors and near misses occur during blood sampling or right before transfusion itself

Most common offenders?...

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Steps to follow during blood sampling

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A) Patient’s identification and Blood Sampling

Blood samples o Taking and labeling at the bedsideo One patient at a time

Ensure patient is correctly identifiedo Asking their names – via wristband, BHT or relativeso Unconscious patient – wristband’s identityo Double checking – get another staff as a witness

Emergency situationso Patient’s temporary unique number for i/d until full

personal details available

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Prepare the necessary equipment for the blood taking

Do not forget to bring along the blood request form

Make sure one bottle and one form each time!

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Always remember to check the patient’s name, ID and hospital RN prior to the blood taking( for fully conscious patient )

Make sure the patient’s name and ID match those in the sticker on BHT

Double check with the name and ID or RN in the patient’s wristband

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Take the blood sample then immediately label it by the BEDSIDE!

DO NOT take sample of more than one patient at one time!

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Label must be clearly written consisting the patient’s name, ID or RN, type of request (GXM/GSH) including how much requested, date and time of collection

DO NOT forget to put the name or initials of the person who took the blood

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Form must be filled up completely and with legible writing!

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Once the labeled blood sample and completed request form of that patient are attached together, then only you can move to the next patient!..please remember this!..

Checklist on the sample labeling

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B) Labeling of SamplePerson who take the blood = person

who label itLabel –oClearly, accurately & immediately at the bedside

oDo not label 2 or more at one timeoHandwritten labels onlyoName, i/d number (must!) ± R/N, date & time of collection

o Initial of person taking the sample

Cont..

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If the staff nurse is helping you…oDoctor’s name and signature on request form

oEnsure samples correctly and accurately taken and checked by S/N

Checklist on filling up the request form

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C) Request FormFill in relevant pt’s info;oName, i/d number, RN , gender, ward, dx,

reason for transfusion & current Hb/pltoBlood group (if known), previous reaction

Unidentified patientsoUse hospital R/N on admission, once pt’s

full name & correct details available – inform blood bank

Requesting doctor;oName must be written clearly & stampedoRequesting ward

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D) Sample for componentsFirst time components request;oBlood sample and request form/soDifferent forms for different

componentsPost transfusion within 3/12 in the same

hospital with no componentsoRequest forms + a copy/carbon copy

of previous request formsIf old copies not available; oNeed new samples

Emergency Transfusion

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Un-crossmatched O/Safe O/emergency OoGroup O Rh positive packed cellsoTransfuse after patient’s condition is fully

assessedoState the reasons on the request form and signo If possible take sample for ABO/Rh grouping

before transfusion

Urgent /emergency crossmatch :oBlood release after X-match issued within 15-20

minoTo inform MO oncall to facilitate the process

Checking blood

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PPDK card/GXM form/blood bag – RIGHT blood

Check appearance: color, clots, cloudy, turbid, foamy, loss of bag integrity

Expiry date

Checklist For Giving Blood or Blood Component To A Patient

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1. Confirm the patient’s:• Name• Hospital RN• Ward

By asking the pt or relative to confirm the patient’s

name and by checking:• The patient’s note• The compatibility label• The blood request form

2. Confirm that the blood or blood component plasma is compatible by checking the blood group on :• The patient’s note• The compatibility label• The blood request form

3. Check for any change in colour, expiry date, leakage, etc. of the blood or blood

Component

4. In the patient’s notes, record :• The date of transfusion• The time of transfusion• The number of units of blood or blood components given• The blood or blood component unit numbers

5. Sign the patient’s note

Informed consent

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Informed – explain /inform regarding benefits, risks and alternative to transfusion

Patient –Understand the issues discussedShould be given opportunity to ask QsInformed decisions must be documentedIf patient unable to give consentNext of keenEmergency or no family members around –

note the urgency, 2 clinicians agreement & documentation

Patient identification checklist prior to transfusion

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Ask patient to state his/her nameNEVER ask “Is your name”….?What is your IC / DOB?Match patient’s wristband with

blood bag and GXM formRight blood to the right patient2 verifiers

Transfusion process

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Slow transfusion- First 15 mins @ 50

mls /hr @ (3-5 mls/min)

Monitor vital signs- BP, PR and temp- Listen to patient’s

complaints..

Time limit for transfusion

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Red cello Transfuse within 30 mins of removing the unit

from the blood refrigeratoro≤ 4 hours to completion

PlateletoShould be kept at 20-24⁰C ( not in the freezer)o Transfusion should start ASAP after collection

from PDNo< 30 min duration

Plasmao Transfuse ASAP after collected from PDNoShould be completed as tolerated by the

patient

Simultaneous administration of fluid

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Red cell concentrates may be diluted with sodium chloride 0.9% to improve the flow rate

NOT for other solutionoRinger lactate contain calcium additive can cause citrated blood to clot

o5% dextrose solution can cause haemolysis

Transfusion reaction

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An adverse reaction to any unit of blood or blood component transfused

Classification

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AcuteoOccuring during the transfusion or within 24h after its completion

DelayedoOccuring at least 24h after transfusionoBut can be days, weeks, months or years later

• Can be classified further as immunologic or non-immunologic in origin

Immune mediated

Non-immune mediated

Immune mediated

Non-immune mediated

1.Acute haemolytic reaction

1.Circulatory overload (TACO)

1.Delayed haemolytic transfusion reaction

1.Iron overload (transfusion induced haemosiderosis)

2.Febrile non haemolytic transfusion reaction

2.Bacterial contamination

2.TAGVHD 2.Disease transmission

3.Allergic reaction (e.g: urticaria, anaphylaxis)

3.Non-immune haemolytic reaction (RBC damage)

3.Alloimmunization

4.TRALI 4.Massive transfusion

4.PTP

Acute Delayed

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Transfusion reaction Mx

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Initial management :oSTOP the transfusionoAssess pt’s ABC, maintain IV line

Call blood bank MOInvestigateoDescribe types of transfusion reaction

oFill up transfusion reaction form

Investigation for transfusion reaction

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Blood sampleo10 mls of clotted blood in plain tube/EDTAoRepeat ABO/Rh grouping, repeat crossmatchoAntibody screening, Coomb’s test

2-5 mls EDTA tube for FBP - ?features suggestive of haemolysis

Urine sample – Hb, RBC and urobilinogenBlood bag unit and its transfusion setAll tubings should be changed, in case of

further transfusionRepeat blood samples and urine after 24H

Summary

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~80% of transfusion errors and near misses occur in the ward due to HUMAN ERROR

House officers, nurses and paramedics play a vital role to avoid this

Must pay particular attention to ;oSteps of blood taking especially on the pt’s identification, labeling and pre-transfusion form

oPatient’s ID before transfusion take placeoAlways check and re-check..

Cont..

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Safe transfusion practice = right blood + right patient + right place + right time + right indication

Remember…Safe transfusion practice can save a patient’s life but unsafe transfusion may result in fatality!

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