Transfusion Error and Near MissesHow to Avoid in Clinical Setting

CME for House Officers and Paramedics in HKL Prepared by : Blood transfusion team subcommittee HKL as part of QA/QI project 2011

QA/QI Project 2011 - Kumpulan A

Introduction
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.

QA/QI Project 2011 - Kumpulan A

The rationale behind the issue

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 QA/QI Project 2011 - Kumpulan A year!

QA/QI Project 2011 - Kumpulan A

Cont..
~ 69% of cases were caused by HUMAN

ERROR! Example of errors include :

i)

ii)
iii) iv) v)

Blood taking / sampling Handling of sample Lab testing Blood retrieval from fridge Pts ID and bedside checking before transfusion

QA/QI Project 2011 - Kumpulan A

 Most errors and near misses occur during

blood sampling or right before transfusion itself Most common offenders?...

QA/QI Project 2011 - Kumpulan A

QA/QI Project 2011 - Kumpulan A

Steps to follow during blood sampling

A) Patients identification and Blood Sampling Blood samples
o o

Taking and labeling at the bedside One patient at a time

Ensure patient is correctly identified

o
o o

Asking their names via wristband, BHT or relatives Unconscious patient wristbands identity Double checking get another staff as a witness
Patients temporary unique number for i/d until full personal details available

Emergency situations
o

QA/QI Project 2011 - Kumpulan A

 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! QA/QI Project 2011 - Kumpulan A

 Always remember

to check the patients name, ID and hospital RN prior to the blood taking( for fully conscious patient )

QA/QI Project 2011 - Kumpulan A

Make sure the patients name and ID match those in the sticker on BHT

Double check with the name and ID or RN in the patients wristband

QA/QI Project 2011 - Kumpulan A

 Take the blood

sample then immediately label it by the BEDSIDE! DO NOT take sample of more than one patient at one time!
QA/QI Project 2011 - Kumpulan A

 Label must be clearly

written consisting the patients 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 QA/QI Project 2011 - Kumpulan A the blood

 Form must be filled

up completely and with legible writing!

QA/QI Project 2011 - Kumpulan A

 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!.. QA/QI Project 2011 - Kumpulan A

Checklist on the sample labeling

B) Labeling

of Sample Person who take the blood = person who label it Label o Clearly, accurately & immediately at the bedside o Do not label 2 or more at one time o Handwritten labels only o Name, i/d number (must!) R/N, date & time of collection o Initial of person taking the sample QA/QI Project 2011 - Kumpulan A

Cont..
If the staff nurse is helping you

o Doctors name and signature on request

form o Ensure samples correctly and accurately taken and checked by S/N

QA/QI Project 2011 - Kumpulan A

Checklist on filling up the request form

C) Request Form
Fill in relevant pts info; o Name, i/d number, RN , gender, ward, dx, reason for

transfusion & current Hb/plt o Blood group (if known), previous reaction Unidentified patients o Use hospital R/N on admission, once pts full name & correct details available inform blood bank Requesting doctor; o Name must be written clearly & stamped o Requesting ward
QA/QI Project 2011 - Kumpulan A

D) Sample for components

First time components request; o Blood sample and request form/s o Different forms for different components
Post transfusion within 3/12 in the same hospital

with no components o Request forms + a copy/carbon copy of previous request forms If old copies not available; o Need new samples
QA/QI Project 2011 - Kumpulan A

Emergency Transfusion
Un-crossmatched O/Safe O/emergency O

o Group O Rh positive packed cells

o Transfuse after patients condition is fully

assessed o State the reasons on the request form and sign o If possible take sample for ABO/Rh grouping before transfusion
Urgent /emergency crossmatch : o Blood release after X-match issued within 15-20
QA/QI Project 2011 - Kumpulan A

min

Checking blood
PPDK card/GXM

form/blood bag RIGHT blood Check appearance: color, clots, cloudy, turbid, foamy, loss of bag integrity Expiry date

QA/QI Project 2011 - Kumpulan A

Checklist For Giving Blood or Blood Component To A Patient

1.

Confirm the patients: Name Hospital RN

Ward

By asking the pt or relative to confirm the patients name and by checking:

The patients note The compatibility label The blood request form The patients 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 :

3. Check for any change in colour, expiry date, leakage, etc. of the blood or blood Component 4. In the patients 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 patients note

QA/QI Project 2011 - Kumpulan A

Informed consent
Informed explain /inform regarding benefits, risks and alternative to transfusion Patient Understand the issues discussed Should be given opportunity to ask Qs Informed decisions must be documented If patient unable to give consent Next of keen Emergency or no family members around note the urgency, 2 clinicians agreement & QA/QI Project 2011 - Kumpulan A documentation

Patient identification checklist prior to transfusion

Ask patient to state his/her name

NEVER ask Is your name.?

What is your IC / DOB? Match patients wristband with blood bag

and GXM form Right blood to the right patient 2 verifiers

QA/QI Project 2011 - Kumpulan A

Transfusion process
Slow transfusion

- First 15 mins @ 50 mls

/hr @ (3-5 mls/min) Monitor vital signs - BP, PR and temp - Listen to patients complaints..

QA/QI Project 2011 - Kumpulan A

Time limit for transfusion

Red cell o Transfuse within 30 mins of removing the unit from

the blood refrigerator o 4 hours to completion Platelet o Should be kept at 20-24C ( not in the freezer) o Transfusion should start ASAP after collection from PDN o < 30 min duration Plasma o Transfuse ASAP after collected from PDN o Should be completed as tolerated by the patient
QA/QI Project 2011 - Kumpulan A

Simultaneous administration of fluid

Red cell concentrates may be diluted with

sodium chloride 0.9% to improve the flow rate NOT for other solution o Ringer lactate contain calcium additive can cause citrated blood to clot o 5% dextrose solution can cause haemolysis

QA/QI Project 2011 - Kumpulan A

Transfusion reaction
An adverse reaction to any unit of blood or

blood component transfused

QA/QI Project 2011 - Kumpulan A

Classification
Acute

o Occuring during the transfusion or within

24h after its completion

Delayed
o Occuring at least 24h after transfusion o But can be days, weeks, months or years

later Can be classified further as immunologic or QA/QI Project 2011 - Kumpulan A non-immunologic in origin

Acute
Immune mediated 1.Acute haemolytic reaction Non-immune mediated 1.Circulatory overload (TACO) Immune mediated 1.Delayed haemolytic transfusion reaction

Delayed
Non-immune mediated 1.Iron overload (transfusion induced haemosiderosis)

2.Febrile non haemolytic transfusion reaction 3.Allergic reaction (e.g: urticaria, anaphylaxis) 4.TRALI

2.Bacterial contamination

2.TAGVHD

2.Disease transmission

3.Non-immune haemolytic reaction (RBC damage)

3.Alloimmuniz ation

4.Massive QA/QI Project 2011 - Kumpulan A transfusion

4.PTP

Transfusion reaction Mx
Initial management :

o STOP the transfusion

o Assess pts ABC, maintain IV line Call blood bank MO Investigate o Describe types of transfusion reaction o Fill up transfusion reaction form

QA/QI Project 2011 - Kumpulan A

Investigation for transfusion reaction

Blood sample

o 10 mls of clotted blood in plain

tube/EDTA o Repeat ABO/Rh grouping, repeat crossmatch o Antibody screening, Coombs test 2-5 mls EDTA tube for FBP - ?features suggestive of haemolysis Urine sample Hb, RBC and urobilinogen QA/QI Project 2011 - Kumpulan A Blood bag unit and its transfusion set

Summary
~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 ; o Steps of blood taking especially on the pts identification, labeling and pre-transfusion form o Patients ID before transfusion take place o Always check and re-check..
QA/QI Project 2011 - Kumpulan A

Cont..
Safe transfusion practice = right blood +

right patient + right place + right time + right indication RememberSafe transfusion practice can save a patients life but unsafe transfusion may result in fatality!

QA/QI Project 2011 - Kumpulan A

QA/QI Project 2011 - Kumpulan A