Pennsylvania Patient Safety Advisory Improving the Safety of the Blood Transfusion Process ABSTRACT Pennsylvania Patient Safety Authority Data Patient death or disability associated with incompatible There have been 535 blood transfusion-related blood is one of the Centers for Medicare and Medic- reports submitted to the Pennsylvania Patient Safety aid Services Hospital-Acquired Conditions and is listed Authority’s reporting system from July 2008 through as one of the National Quality Forum’s Serious Report- July 2009. Analysts queried the database for events able Events. The Joint Commission’s 2009 National associated with blood transfusions, errors related to Patient Safety Goal 01.03.01 lists the elimination procedure, and complications of procedures, treat- of transfusion errors related to patient identification. ments, and tests. These included 14 Serious Events, Blood component transfusions to nondesignated 1 of which resulted in death. The death occurred in recipients occur in about 1 of 10,000 transfused units. the operating room, and additional patient identifica- Two-thirds of these errors are associated with incorrect tion was identified as a recommendation to prevent blood recipient identification occurring at the patient’s future blood transfusion errors. Other Serious Events bedside. There were 535 reports of blood transfusion- and Incidents involved mismatched units; events related events submitted to the Pennsylvania Patient related to blood component testing collection; blood Safety Authority during the 13-month period from July products dispensed, distributed, or administered; or 2008 through July 2009. Reports involved mismatched the wrong patient being transfused. units; events related to blood component collection; blood products dispensed, distributed, or adminis- Events reported to the Authority can be organized tered; or wrong patients being transfused. Recipient into three stages: (1) errors during pre-analysis includ- identification at blood collection and administration ing sample collection, (2) errors in laboratory through are essential to the safety of the total blood transfusion issue, and (3) errors post issue in clinical areas. Some process. The safe transfusion of blood components events occurred in multiple stages (see Table 1). is a complex process involving many departments, Pre-Analysis Area Errors multiple staff, and several steps. This article focuses on the process for safe transfusion and the risk reduction According to Pagliaro and Rebulla, the most common strategies that decrease the incidence of transfusion adverse event during blood transfusion therapy occurs errors by developing adequate quality systems to during pre-analysis (e.g., blood specimen collec- ensure correct patient identification of the transfusion tion), typically at the patient’s bedside.5 This pattern candidate, assigning clear responsibilities to quali- was also evident in reports to the Authority, with fied staff including a transfusion safety officer, and 61% of reports describing errors in this stage of the using identification technologies such as bar-coding or blood transfusion process (see Table 1). Pre-analysis radiofrequency identification tags. (Pa Patient Saf Advis errors during blood specimen collection may include 2010 Jun;7[2]:33-40.) delays in collection, wrong blood in tube collected, or incorrect or no label applied to the specimen. Of the 344 errors identified in the pre-analysis area, 141 (41%) events involved the wrong patient because the Problem specimens did not match historical records or failed the Delta checks (comparing prior test results from a The Agency for Healthcare Research and Quality’s patient to determine if a newly obtained test result is report, “Statistics on Hospital-Based Care in the U.S., 2007,” found that the number of blood transfusions from 1997 to 2007 increased 140% from 1.1 million Table 1. Stages in the Blood Transfusion to nearly 2.7 million.1 Blood transfusions occurred in Process, July 2008 through July 2009 1 of every 10 hospital stays that included a procedure NUMBER during the same time period. Patient death or disabil- OF REPORTS PATIENT ity associated with incompatible blood is one of the STAGES* (N = 535) % HARM Centers for Medicare and Medicaid Services Hospital- Pre-analysis (e.g., sample 344 61 2 Acquired Conditions2 and is listed as one of the collection, specimen labeling) National Quality Forum’s Serious Reportable Events.3 Lab (e.g., serology, 101 18 5 The Joint Commission’s 2009 National Patient computer transcription, Safety Goal regarding blood transfusions includes the transfusion unit labeling) elimination of transfusion errors related to patient Clinical at the bedside 115 21 10 identification.4 Blood component transfusions to with transfusion units (e.g., unintended recipients occur in about 1 out of 10,000 bedside testing, transfusion transfused units, and two-thirds of these errors are unit mix-ups) associated with incorrect blood recipient identifica- * Some events involving patient harm occurred in multiple stages. tion that occurs at the patient’s bedside.5 Vol. 7, No. 2—June 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 33 Pennsylvania Patient Safety Advisory likely to be in error) or because the wrong labels were Table 2. Errors in the Pre-Analysis Stage placed on the tubes. Other pre-analysis area errors of Blood Transfusion, July 2008 through included those with incorrect patient information July 2009 (19%), missing independent double checks (7%), NUMBER OF PATIENT missing computer transcription (6%), miscommunica- OCCURRENCES HARM tions (6%), blood bank armband issues (5%), missing ERRORS (n = 344) (n = 2) consents (1%), and others (15%) (see Table 2). Exam- ples reported to the Authority include the following: Wrong patient (e.g., did not 141 1 match historical records, There was an outstanding, [unlabeled blood] speci- failed Delta test, wrong label men from the morning collection. The [phlebotomist] on tube) found the missing labels in a [patient] room, remem- Incorrect patient information 64 bered drawing the blood from a patient [with the (e.g., missing blood bank number on band, incorrect missing specimen labels], and [realized] she must date of birth, first and last have placed these labels on a [blood] specimen from name mix up, two different another patient. [It was] determined [that another] names used for same patient) patient had been labeled incorrectly. Missing two independent 25 double checks Type and cross was ordered for a patient. When the lab [completed testing, the result] did not match [the Computer issue (e.g., wrong 22 order, no order, transposed patient’s] previous blood type. The [original] blood numbers) had been drawn from another patient, and the wrong Communication issues (e.g., 20 1 label [had been] applied. special instructions, between A lab phlebotomist collected a specimen for a type healthcare providers) and cross match on a patient. Blood bank typed the Blood bank armband issues 17 specimen as A+. The patient was on record in the (e.g., missing armband, incorrect armband number) blood bank as being O+. The phlebotomist drew the original specimen on the wrong patient [and misla- Missing signed consent 4 beled the specimen at the time of collection]. Other 51 Type and cross match specimens were received in the blood bank. No phlebotomist’s initials were on the labels. A patient’s blood was sent for type and screening. The patient’s blood type in the chart was O+. The Laboratory Errors blood bank called and stated that the blood type Laboratory errors are those that occur in the blood [for this patient] was A+. The patient had a blood bank and may include errors in computer transcrip- redraw, and the lab [staff] stated that blood bank tion, patient identifier mismatches, testing errors, or [staff] had made an [incorrect] computer entry. incorrect blood component released from the blood Clinical Errors bank. Of the 101 errors identified in the laboratory areas, 15 (15%) involved the wrong blood component Blood transfusion errors that occurred or were dispensed. Other laboratory area errors included reported in clinical areas that excluded pre-analysis those with delays (13%), blood components that were errors consist of events that involve bedside testing dispensed before all testing was completed (12%), or equipment used at the bedside, mix-up of transfu- computer entry errors (11%), missing or incorrect sion units, and actual transfusion of the blood to the unit tags (11%), incorrect antibody screening (9%), incorrect patient. Of the 115 errors identified in the expired blood components (7%), missing patient clinical stage of the blood transfusion process, 40 identifier information (5%), mislabeled blood speci- (35%) involved patient reactions to the blood compo- men tubes (3%), special orders not followed (2%), nents. Other clinical area errors included intravenous inability to open blood storage cabinet (1%), and oth- line issues (17%), incorrect blood components admin- ers (12%) (see Table 3). Examples of laboratory errors istered (12%), expired or wasted blood component reported to the Authority include the following: (8%), no type and cross laboratory testing before blood component administered (7%), incomplete documen- When the lab staff was signing out a unit of blood tation (6%), identification band issues (5%), incorrect [to dispense to the nurse], it was noted [that] the unit patient received blood component (4%), inadvertent number on the blood bank slip was incorrect. Upon transfusion of type and hold component (1%), and investigation, [a transcription error was found]. others (5%) (see Table 4). Examples of clinical errors [The blood bank issued] one unit of blood for this reported to the Authority include the following: patient. When the nurse went to transfuse [the blood], The blood product was released from the blood bank the bracelet and the medical record number on the according to the patient identification on the form, bracelet were checked but did not match. [It] appeared and [the blood] was administered without confirming that [the numbers] were transposed between [the medi- the product label to the patient’s [identification]. The cal record number and the patient account number]. patient received an incorrect unit of packed red blood Page 34 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 2—June 2010 Pennsylvania Patient Safety Advisory recommendations from this group included using Table 3. Errors in the Laboratory Stage the Centers for Disease Control and Prevention’s of Blood Transfusion, July 2008 through National Healthcare Safety Network as the national July 2009 surveillance system for recipient outcomes of blood NUMBER OF PATIENT and blood products.7 The College of American OCCURRENCES HARM ERRORS (n = 101) (n = 5) Pathologists (CAP) offers accreditation that focuses on the quality of laboratory testing and transfusion ser- Wrong blood component 15 2 dispensed vices that meets national and local standards. CAP’s Delay (e.g., staffing, no 13 1 focus is on patient and blood sample identification, available blood) testing procedures and equipment, identification and Dispensed before testing 12 investigation of transfusion reactions, and competency (e.g., cross match, ABO of staff.8 Blood and transfusion centers may also be compatibility, type and cross) accredited by the Joint Commission, which focuses Computer issues (e.g., 11 on the use, prescription, and administration of incorrect ABO) blood components.9 Incorrect or missing blood 11 bank unit tags (e.g., machine Blood Transfusion Process broken) While each element of the blood transfusion process Incorrect antibody screening 9 presents inherent risk, every aspect depends on the Expired (e.g., cross match, unit) 7 accurate and successful completion of the prior step. Missing armband information 5 1 (A reprinted, sample diagram of this process, titled (e.g., missing date of “Transfusion Process Map,” is available from the Au- birth, wrong blood bank thority online at http://www.patientsafetyauthority. identification number) org/EducationalTools/PatientSafetyTools/Pages/ Mislabeled blood specimen 3 1 home.aspx.) The blood transfusion process outlines tube the precise and detailed description of each step dur- Special orders (e.g., 2 ing standard and exceptional conditions.10 Stainsby et transfusion prepared without leukocyte filter, blood al. analyzed 2,087 blood transfusion adverse events component not irradiated) during a seven-year period and found that there were Unable to open blood storage 1 1,393 (67%) instances of incorrect blood components cabinet (e.g., access code not being transfused.11 Approximately 50% of these working) occurrences involved multiple errors in the blood Other 12 transfusion process, which most frequently occurred during the pretransfusion bedside check.5,11 Osby et al. outlined specific steps in the blood trans- cells, resulting in an intravascular hemolytic reaction fusion process that organizations can use to identify that required fresh frozen plasma and platelets to risk areas: prescribing blood components, submit- correct the coagulopathy. ting blood samples to the blood bank, issuing blood components from the blood bank, transfusing the A patient was ordered to have a transfusion of fresh patient, and monitoring the patient for transfusion frozen plasma. Approximately 100 mL infused when reactions.12 the physician [cancelled the order.] Two patient records [had been] opened at the [time of the transfu- Prescribe Blood Components sion order, which had been written on the wrong Blood hemoglobin concentration is only one deter- patient’s chart]. minant of tissue oxygenation.13 Medical indications for transfusion should exist and be thoroughly docu- Guidelines mented before prescribing blood components. Absent Several organizations and regulatory bodies provide signs of hypoxia, a patient may not necessarily require safety guidance for transfusion medicine. The U.S. blood products. A decision to transfuse is based on Food and Drug Administration (FDA) licenses and clinical presentation and supported by laboratory registers blood and transfusion centers. FDA’s role results.11 If the laboratory results and the patient’s is to inspect each facility’s documentation of each clinical presentation do not match, a decision to step during collection, processing, compatibility test- transfuse may occur based on incorrect results or ing, storage, distribution of blood components, and analytical errors. In addition, telephoned results may adverse event investigation.6 AABB (formerly the be erroneously transcribed or assigned to the incor- American Association of Blood Banks) is a standard- rect patient, even if the reading back of test results is setting professional organization in transfusion properly performed.11 Patient consent for transfusion medicine.7 In 2006, AABB, the U.S. Department allows the patient to make an informed choice regard- of Health and Human Services, and representation ing the risks, benefits, indications, and alternatives for from government and nongovernment organizations elective or nonemergency blood transfusion, which formed the U.S. Biovigilance Network. Reporting also includes the right to refuse the transfusion.10,12 Vol. 7, No. 2—June 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 35 Pennsylvania Patient Safety Advisory samples and inadvertent administration of the wrong Table 4. Errors in the Clinical Stage of blood to the wrong patient. Blood Transfusion, July 2008 through July 2009 In June 2009, nine facilities in the northeast region NUMBER OF PATIENT of Pennsylvania began working collaboratively with OCCURRENCES HARM the Authority to identify and eliminate phlebotomy ERRORS (n = 111) (n = 10) specimen mislabeling—one of the most common Reaction (e.g., fever, rigors, 40 4 pre-analysis errors. These facilities committed to a tachycardia, hypotension, year-long process of monitoring, investigating, and chest pain, headache, redesigning systems across many disciplines and units. urticaria, dyspnea) Identified best practices from this collaborative will Intravenous line issues 19 2 (e.g., infiltration, leaking, no be shared in future updates in the Advisory. To learn filter, timing of greater than more about this collaborative, visit the Authority’s four hours) Web site at http://www.patientsafetyauthority.org/ Wrong blood component 14 3 ADVISORIES/AdvisoryLibrary/2009/Sep6(3)/ administered Pages/107.aspx. Expired/wasted blood 9 Issue Blood Components from the Blood Bank component No type and cross before 8 As previously noted, the laboratory discovery of the receiving blood component wrong blood in a tube specimen when comparing (e.g., trauma, emergency the results of two or more specimens from the same department) patient that have been collected at different times is Incomplete documentation 7 known as a Delta check. If there is no historical labo- (e.g., unit tag saturated, ratory data on the patient, an error such as the wrong numbers obscured tag numbers, no identification blood in tube could escape detection and result in the numbers) wrong blood component being transfused, leading to Identification band issues 6 an acute hemolytic transfusion reaction.12 A dispro- (e.g., no blood bank band, portionately high number of laboratory errors take blood bank identification place outside the usual blood bank hours, particularly number cut off, improperly when there are fewer staff.11 While routine blood labeled blood bank band) groupings are automated in the blood bank, manual Wrong patient received blood 5 1 component techniques may be needed for urgent blood grouping. These manual techniques are inherently unsafe and Order to type and hold only 1 but was mistakenly transfused have the potential for errors in interpretation and documentation.11 Transfuse the Patient Submit Blood Sample to the Blood Bank The bedside check verifies the identity of the Proper specimen collection is the one of the most intended recipient and matches it to the identity of important steps of transfusion safety.14 Twenty-one the person about to receive the blood transfusion. months of data collection and analysis at a university Verification takes place in the presence of the patient, hospital by Quillen and Murphy revealed that the using two licensed persons and a three-way check emergency department accounted for the dispro- that includes the blood component tag, compatibility portionately high number of wrong blood in tube slip, and patient wristband.12 This is the most critical specimens with most errors having major mislabeled step of transfusion safety and the final opportunity to specimens.14 Major mislabeling specimens are those interrupt any incorrect blood component.13 that are unlabeled, have mismatched information on specimen and requisition, or for which the cur- Administer Blood Components rent specimen does not match the historical record According to AABB, “No medications or solutions on file.14 According to Ahrens et al., obtaining the may be routinely added to or infused through the pre-analysis sample for testing is by far the weakest same tubing with blood or blood components with link in the safety chain of blood transfusion.15 This the exception of 0.9% Sodium Chloride, Injection pattern was also evident in reports to the Authority, (USP), unless (1) they have been approved for this use with nearly two-thirds (61%) of the blood transfusion by the FDA or (2) there is documentation available to reports describing errors in the pre-analysis stage. show that the addition is safe and does not adversely Stainsby et al. identified other blood sample issues: affect the blood or blood component.”16 Other con- labeling blood sample tubes away from the bedside, siderations for blood component safety include types failing to check the patient’s identity, failing to use of administration tubing, intravenous access, and preprinted labels, and using poor technique in blood filters used with transfusions; infusion rates; and sampling, which affects laboratory results.11 Errors the use of infusion pumps.12 Bar-coded systems and with specimen collection may be slip errors, which other technologies are better suited to the repetitive are caused by staff distraction, fatigue, or inattention. data matching that occurs with blood transfusions. Such errors may result in the mislabeling of blood Bar-coded systems are not subject to distraction and Page 36 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 2—June 2010 Pennsylvania Patient Safety Advisory can help organizations improve the labeling of blood antibodies with secondary complications, formation samples, dispensing of blood components, and iden- of platelet-specific antibodies, and graft-versus-host tifying the patient at the bedside.13 Studies indicate disease. Late complications may have an onset of days that many facilities use bar-coded labels, but there to months following the transfusion.12,19 continue to be issues of the incorrect bar-coded label from one patient to another, wrong blood in tube, or Risk Reduction Strategies blood being administered to a nondesignated blood Risk reduction strategies assist facilities to improve the recipient with blood that appears correctly labeled. safety of blood transfusions by including all steps in The positive donor-recipient identification at blood the process from collection, compatibility test, product collection and administration is essential to the total issue from the blood bank, to blood administration at blood transfusion process, so that if a transfusion the bedside, monitoring of transfusion reactions, and error is detected, process monitoring and any action thorough documentation.14 Though some strategies taken may be tracked.13,17 may be considered “low-tech,” a simple approach may Other technologies such as radiofrequency iden- have more appeal and be easier to implement than tification tags (RFID) hold considerably more some of the automated interventions.20 Consider the information, are more user friendly than bar-code following strategies for formally engineering or re- equipment, and may help organizations to ensure engineering the blood transfusion process: the correct blood and amount is administered to the ■ Establish an interdisciplinary transfusion commit- correct patient.5,13,15,18 There are two kinds of RFID tee that includes a transfusion safety officer.5,12 technology: active and passive. Active RFID refers to ■ Evaluate current organizational blood transfusion technology in which the chip is battery-powered and practices, and re-engineer needed changes to trans- emits energy that can be read over a distance (e.g., fusion systems or processes.12 cellular phone). Tags with active RFID technology can be used for asset tracking within facilities to locate ■ Develop organizational blood transfusion poli- valuable equipment.13 Passive RFID technology is read cies and procedures using AABB guidelines that only when it is brought in close proximity to an elec- include the use of two patient identifiers. All blood tronic RFID reader.13 Machine-readable identification components should be refrigerated or frozen and technology is ideally suited to meet the needs of the stored according to FDA and AABB requirements bedside check prior to the administration of blood and transfused before the expiration date indicated components.13 on the blood component label. Any component that was previously frozen must have an expiration Monitor for Transfusion Reactions time assigned when the unit is thawed.6,7,12 Patients who receive any blood component transfu- sion are monitored for early and late complications. ■ Review prescriber ordering procedure of blood Routine monitoring includes documentation that a components. The use of computerized prescriber patient is tolerating the transfusion without adverse order entry (CPOE) provides a structured, legible, events. If the patient exhibits any signs of a transfusion and traceable communication between the pre- reaction, the transfusion is stopped immediately, vital scriber and the blood transfusion service. CPOE signs are obtained, and a comparison of the patient’s combined with computer-assisted decision support armband with the blood component tag and label are provides readily available information intended to performed.12 Patient monitoring is a crucial part of assist the clinician in making proper transfusion the safe transfusion process so transfusion reactions decisions using the alerts built into the system. can be promptly recognized and safely managed. The These alerts provide the prescriber with valuable patient should be very closely monitored in the first guideline information at the time of the blood half hour of an elective transfusion, according to the request and provide feedback to the clinician on organization’s transfusion policy, and when adequate the indication for the transfusion.13 staffing in the patient care area is ensured to provide ■ Consider the use of a blood transfusion record adequate monitoring for a transfusion reaction. that guides the prescriber to indicate the basis for Any sign, symptom, or untoward event of the blood the transfusion when one is ordered.12 Algorithms transfusion is documented so that the patient may be may be used to identify appropriate transfusions.13 treated appropriately.12 Examples of early noninfec- Davies et al. indicated a 12% decrease in transfu- tious complications include febrile nonhemolytic sions in the year following the introduction of the transfusion reaction, circulatory overload, hemolysis, electronic prescribing of blood components using transfusion-related acute lung injury, mild to severe algorithms which incorporated guidelines.21 The allergic reaction, and electrolyte or coagulation abnor- prescription for the administration of a blood malities, which may have an occurrence onset during component provides instructions regarding the rate or within hours of the transfusion.12,19 Noninfectious and volume of the transfusion. Particular care must late complications may include the formation of red be exercised when prescribing for infants, children, cell antibodies with secondary complications, iron and small adults, during which failure to adjust overload, immune suppression with secondary com- the quantity can result in overtransfusions and can plications, formation of human leukocyte antigen lead to serious morbidity or mortality.11 Vol. 7, No. 2—June 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 37 Pennsylvania Patient Safety Advisory ■ Review patient consent for blood components uncover prescribing practices that may be inappro- and ensure right for refusal clause appears on the priate, ensure correct patient identification of the consent. The consent includes information about transfusion candidate, assign clear responsibilities to the infectious and noninfectious risks of transfu- qualified staff, and consider the development of a sion, given in an appropriate reading level and in transfusion safety officer. Guidelines should be clear, the patient’s native language. The consent also unambiguous, and readily accessible. includes the opportunity for the patient to ask Notes questions about the transfusion and should be obtained as soon as it has been determined that 1. Agency for Healthcare Research and Quality. HCUP there is a possibility that a transfusion may be Facts and Figures Statistics on Hospital-Based Care in needed.12 the United States, 2007 [online]. 2009 Sep [cited 2009 Oct 5]. Available from Internet: http://www.hcup-us. ■ Monitor, track, and trend all blood samples for ahrq.gov/reports/factsandfigures/2007/TOC_2007.jsp. type and cross, type and hold, wrong blood in tube, mislabeled tubes, and issued blood com- 2. Centers for Medicare and Medicaid Services. CMS ponents from blood bank. Blood bank hours of improves patient safety for Medicare and Medicaid by operation and staffing issues should be considered addressing never events [fact sheet online]. 2008 Aug 4 with the review or development of blood transfu- [cited 2008 Aug 12]. Available from Internet: http:// sion safety. (For example, elective transfusion www.cms.hhs.gov/apps/media/press/factsheet.asp? should be strongly discouraged in the off hours Counter=3224&intNumPerPage=10&checkDate=& due to possible staffing shortages in the laboratory checkKey=&srchType=1&numDays=3500&srchOpt= and on the patient care area.)11 0&srchData=&keywordType=All&chkNewsType=6& intPage=&showAll=&pYear=&year=&desc=& ■ Consider the use of a statistical process control to cboOrder=date. monitor the quality of an organization’s errors in patient specimen collection of the blood transfu- 3. Agency for Healthcare Research and Quality. 30 safe practices for better health care [fact sheet online]. 2005 sion processes.13,17 Mar [cited 2009 Oct 5]. Available from Internet: http:// ■ Consider the use of a bedside checklist that www.ahrq.gov/qual/30safe.pdf. lists safe handling of blood components when 4. The Joint Commission. National Patient Safety Goals transfusions are administered.10 Positive patient [2009 Goal 01.03.01 online]. [cited 2009 Oct 5]. Available identification includes matching wristband iden- from Internet: http://www.jointcommission.org/NR/ tification to the blood compatibility label and rdonlyres/868C9e07-037f-433d-8858-0d5faa4322f2/0/ matching the two patient identifiers with the revisedchapter_HAP-NPSG_20090924.pdf. blood request.13,20 In addition, the review of blood component compatibility, expiration date, unit 5. Pagliaro P, Rebulla P. Transfusion recipient identifica- number, and ABO/Rh type for both the recipient tion. Vox Sang 2006 Aug;91(2):97-101. and the unit should be present as well as special 6. U.S. Department of Health and Human Services, Food attribute alerts.12,13 and Drug Administration, Center for Biologics Evalu- ■ Consider the use of bar-codes or RFID to ensure ation and Research. Guidance for Industry: Biological the correct blood and amount goes to the correct product deviation reporting for blood and plasma patient.13 establishments [online]. 2006 Oct [cited 2009 Oct 5]. Available from Internet: http://www.fda.gov/ ■ Ensure that patients have appropriate IV access downloads/BiologicsBloodVaccines/Guidance before picking up blood from blood bank.12 ComplianceRegulatoryInformation/Guidances/Blood/ ■ Transfuse patient within 30 minutes of blood com- UCM062918.pdf. ponent pickup from the blood bank.12 7. AABB. U.S. Biovigilance Network: Investing in patient ■ Monitor patients for early and late transfusion safety and donor health [online]. 2009 [cited 2009 reactions.12 Oct 5]. Available from Internet: http://www.aabb. org/Content/Programs_and_Services/Data_Center/ ■ Document allergic reactions.12 US_Biovigilance_Network. ■ Provide ongoing structured educational opportuni- 8. College of American Pathologists. Recognizing a sus- ties for healthcare practitioners that include annual tainable quality management system [online]. 2009 Sep assessment of blood transfusions competence.5,9 [cited 2009 Oct 5]. Available from Internet: http:// www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_ Conclusion actionOverride=%2Fportlets%2FcontentViewer% The process for safe transfusion is a complex one 2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt% that involves several hospital departments and types 7BactionForm.contentReference%7D=laboratory_ accreditation%2F15189%2Fabout.html&_state= of staff, multiple steps, and hundreds of individu- maximized&_pageLabel=cntvwr. als.17 Facilities may consider risk reduction strategies that decrease the incidence of transfusion errors 9. Joint Commission. A new look at blood transfusion. Jt by the development of adequate quality systems to Comm Perspect Patient Saf 2007 Jan;7(1):1,7-8,12. Page 38 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 2—June 2010 Pennsylvania Patient Safety Advisory 10. Hennenman EA, Cobleigh R, Avrunin GS, et al. 16. AABB. Circular of information for the use of human Designing property specifications to improve the safety blood and blood components [online]. 2009 Aug [cited of the blood transfusion process. Transfus Med Rev 2008 2010 Jan 14]. Available from Internet: http://www. Oct;22(4):291-9. aabb.org/Documents/About_Blood/Circulars_of_ Information/coi0809r.pdf. 11. Stainsby D, Russell J, Cohen H, et al. Reducing adverse events in blood transfusion. Br J Haematol 2005 17. Dzik WS, Beckman N, Selleng K, et al. Errors in patient Oct;131(1):8-12. specimen collection: application of statistical process control. Transfusion 2008 Oct;48(10):2143-51. 12. Obsy MA, Saxena S, Nelson J, et al. Safe handling and administration of blood components: review of practical 18. Taylor CJ, Murphy MF, Lowe D, et al. Changes in prac- concepts. Arch Pathol Lab Med 2007 May;131(5):690-4. tice and organization surrounding blood transfusion in NHS trusts in England 1995-2005. Qual Saf Health Care 13. Dzik W. New technology for transfusion safety. BJH 2008 Aug;17(4):239-43. Review 2006 Nov;136:181-90. 19. Eder AF, Chambers LA. Noninfectious complica- 14. Quillen K, Murphy K. Quality improvement to decrease tions of blood transfusion. Arch Pathol Lab Med 2007 specimen mislabeling in transfusion medicine. Arch May;131(5):708-18. Pathol Lab Med 2006 Aug;130(8):1196-8. 20. Kaplan H. Safer design. Transfusion 2007 May;47(5):758-9. ? 15. Ahrens N, Pruss A, Keisewetter H, et al. Failure of 21. Davies A, Staves J, Kay J, et al. End-to-end electronic bedside ABO testing is still the most common cause of control of the hospital transfusion process to increase incorrect blood transfusion in the barcode era. Transfus the safety of blood transfusion: strengths and weak- Apher Sci 2005 Apr;33(1):25-9. nesses. Transfusion 2006 Mar;46(3):352-64. ? Self-Assessment Questions The following questions about this article may be useful for internal education and assessment. You may use the following 3. A patient was admitted to the hospital for exacerbation of congestive heart failure (CHF). Laboratory results were examples or come up with your own. hemoglobin 6.4, hematocrit 21, and red blood cells 2.6. The attending physician ordered a transfusion, although 1. Which is the most critical strategy to improve the safety of mindful of the patient’s CHF. The physician had consid- the blood transfusion process? ered that the risk of fluid overload was outweighed by the a. Use manual techniques when the laboratory has per- patient’s deteriorating condition and laboratory values. formed routine blood grouping. Precautions were taken pretransfusion, including the b. Use identification technologies such as bar-coding sys- administration of medication in an attempt to prevent any tems or radiofrequency identification tags to improve transfusion reaction. The patient was transfused with one proper specimen labeling. unit of packed red blood cells and, two hours later, became acutely short of breath and hypoxic. Oxygen was adminis- c. Obtain positive donor-recipient identification and veri- tered to the patient, and the physician was summoned to fication during blood collection and administration. the patient’s bedside. Repeated laboratory testing of the d. Provide patient monitoring during blood or blood original blood specimen revealed that the results did not component administration. match the patient’s previous blood type. The original blood 2. Risk reduction strategies to ensure the safety of the blood had been drawn from a different patient, and the wrong transfusion process include all of the following EXCEPT: label had been applied. The patient had received an incor- rect unit of packed cells based on an incorrect blood type. a. Guide prescribers to use algorithms and blood transfu- sion records to indicate the basis for transfusions when In the case study described above, breakdowns or errors ordered. that led to wrong blood delivery associated with transfu- b. Use a standardized algorithm for all patient sions likely included all of the following EXCEPT: populations. a. Verification took place in the presence of the patient. c. Implement a standardized checklist for the safe han- b. Prescribed blood or blood components were based on dling of blood components when transfusions are clinical presentation. administered. c. Failed Delta test occurred in the laboratory. d. Standardize labeling of blood samples using bar-coded d. Unlabeled blood samples were submitted to the systems. blood bank. Vol. 7, No. 2—June 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 39 Pennsylvania Patient Safety Advisory 4. Select the stage in the blood transfusion process in which 5. Routine medication and solutions may be added to or the most common errors occur. infused through the same tubing with blood or blood a. The laboratory stage, which begins when the blood components. specimen is delivered to the laboratory through the a. True distribution of the blood or blood components b. False b. The pre-analysis stage, which begins during collection of blood specimens and typically occurs at the bedside c. The clinical stage, which begins in the clinical area, excludes the pre-analysis stage, and includes additional bedside testing or equipment used at the bedside d. The monitoring stage, which begins in the clinical area after the blood or blood component has been trans- fused and includes monitoring the patient after the transfusion is complete Page 40 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 2—June 2010 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 7, No. 2—June 2010. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2010 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.