Transfusion Error and Near Misses
Transcript of 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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