How to avoid transfusion error sentinel events
December 1, 1999 3 minutes read
How to avoid transfusion error sentinel events
JCAHO recommends training, system redesign
Twelve transfusion error sentinel events have been investigated by the Joint Commission on Accreditation of Healthcare Organizations in the past three years, and the Joint Commission recently issued advice based on the root cause analyses of those events.
According to information released recently by the Joint Commission, 10 of the cases resulted in patient deaths, and the other two patients recovered. Eleven of the cases were hemolytic reactions, while one was an infectious reaction. Eleven of the transfusion reactions took place in a general hospital, with eight occurring in high-risk areas: the operating room, emergency room, intensive care unit, or during resuscitation. One of the 12 cases was in a long-term care organization.
Multiple failures are usually to blame
Incomplete patient/blood verifications were identified as at least one of the causes in eight of the 12 cases. Three of the 12 cases involved the handling or processing of blood samples or blood units for more than one patient at the same time in the same location. In all but one case (contaminated platelets), there were multiple failures to follow established procedures, usually involving the verification of patient identity and correct blood unit for that patient.
The Joint Commission learned of eight of the 12 cases through self-reporting. Three events were reported by state or federal regulatory agencies, and the Joint Commission learned about one case through media coverage.
Transfusions inherently risky and difficult
The report from the Joint Commission notes that blood transfusions involve many factors that increase the risk of an adverse outcome. There is variable input because the patients have different blood types, complexity because of the technical aspects of cross-matching as well as administering and monitoring the effects of blood, and inconsistency because there is no standardization across all hospitals.
Another problem is what the Joint Commission calls "tight coupling." That refers to a situation in which steps in a process happen so closely together that if a failure occurs in one step, there is little opportunity for intervention. With a blood transfusion, it is difficult to interrupt the sequence of the process, especially in an emergency room, operating room, or intensive care unit.
Transfusions also require a higher level of consistency than is reasonably achievable by health care workers without computer support, the report says. Tight time constraints, especially in an emergency room, operating room, or intensive care unit also can increase errors.
The transfusion sentinel events’ root causes fell into these seven general areas:
• patient assessment, such as incomplete patient/blood verification;
• patient assessment, such as the signs and symptoms of a transfusion reaction not being recognized;
• care planning, such as no informed consent for a transfusion;
• laboratory procedures, such as multiple samples cross-matched at the same time or a cross-match being started before the order was received;
• staff-related factors, such as insufficient orientation and training or insufficient staffing levels;
• equipment-related factors, such as blood for multiple operating room patients being stored in the same refrigerator;
• information-related factors, such as incomplete communication among caregivers or patient identification band, specimen label, or blood-label errors.
Prevention strategies suggested
The organizations that have experienced sentinel events suggested staffing and training improvements, along with technical system redesign efforts such as enhanced computer support or new patient identification band system. Those organizations also suggest discon tinuing use of an operating room refrigerator for multiple blood units or adding laboratory workstations.
In addition, the Joint Commission suggests the following actions:
• Prohibit simultaneous cross-matching of multiple patients by the same technologist.
• Do not use the patient’s room number to identify blood samples or transfusion units.
• Consider the use of "unique" identification bands for patients receiving blood transfusions.
• Introduce a computerized verification step into the process.
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