Post on 11-Jan-2016
description
transcript
Module 7: Errors in transfusion
Transfusion Training WorkshopKKM 2012
Sources of Error
Case 1
60 year-old man, hospital RN 721677
Post-BKA
Hb 7 g/dL
2 PC requested
Case 1 – cont’d
Sample and request form arrived at BB
BB staff checked sample and request form
Sample had a different patient’s name, IC and RN no.
Case 1 – cont’d
Patient requiring GXM
60 year-old man
Orthopedic ward 5C
Name: Mr YKC
Label on sample
28 year-old lady
Maternity ward 4D
Name: Mrs KB
Case 1 – what happened…
Patient requiring GXM
60 year-old man
Orthopedic ward 5C
Name: Mr YKF
RN 721677
Blood group O
Label on sample
28 year-old lady
Maternity ward 4D
Name: Mrs SW
RN 721667
Blood group AB
Always make sure the sample is labeled for the right patient
AT THE BEDSIDE with at least 2 patient identifiers
Name IC no
Best practice 1
Identify and inform patient Draw blood sample Label sample by
handwriting at bedside Collect or print sticker
label Check printed label
matches handwritten details before pasting on sample tube
Best practice 2
Print the patient’s sticker label
Identify correct patient
Inform patient (the need for transfusion)
Draw blood sample
Check label with patient
Stick label (at bedside)
Case 2
B/O RR, premature infant @ 27 weeks
Day 13 OL on ventilator
14th April 2011 @ 1235h: received GXM request
Grouped as AB Rh pos
Previous record: group O Rh positive
Re-grouping with second sample: AB Rh pos
Case 2 – cont’d
Possible explanation: 1st grouping was wrong
So BB staff went up to the ward
Bedside grouping: group O Rh positive
So what happened?
Case 2 – cont’d
What actually happened:
1st sample: Doctor A took blood sample Doctor B labeled the sample Doctor C filled and signed the request form
2nd sample: Doctor D took an unlabeled sample from
the fridge and sent to BB
The SAME doctor or staff who draws the blood sample must also label it
At the bedside
Just imagine if there was no previous record and this was a new patient
If this was an older child, he would have been transfused with AB blood when he is actually group O!
Case 3
28th March 2011: received a GSH sample for Supramaniam A/L Kannan
Grouped as A Rh pos
Previous record: Group O Rh pos
So what went wrong?
Case 3 – cont’d
There were 2 patients with the same first name in the ward
1.Supramaniam A/L Kannan Bed 16
2.Supramaniam A/L Solamalai Bed 23
Bedside grouping Patient 1: Group O Rh pos Patient 2: Group A Rh pos
Case 3 – cont’d
What went wrong:
Doctor A: filled the request form
Doctor B: drew the blood sample from the wrong patient
Doctor A: labeled the sample
How do we prevent errors?
Correct practice at every step
Step 1: the decision to transfuse Avoid inappropriate and unnecessary
transfusions
Inform patient
Fill up request form
Ask patient for blood group if known
Step 2: correct patient identification (prior to blood sampling)
Ask the patient his/ her full name and identification card no. (DOB and MRN)
Check the wrist band (in-patient) or hospital card/ ic (daycare)
Step 3: blood sampling
NEVER pre-label GXM tubes (EDTA) The SAME doctor/ staff must take blood
sample and label the tube NEVER use pre-printed labels Show labeled tube and completed
request form to patient NEVER take blood samples from >1
patient at a time
A
B
CD
Step 4: receipt of blood request BB staff must
make sure sample and request form are properly and correctly labeled
check for any previous transfusion record
Step 5: collection of blood
Bring collection slip and blood box BB staff must check collection slip matches
request form and blood to be collected Withdrawal of units must be documented
Staff name Date Time issued
Inspect colour and expiry date
Collection slip
Blood box ± ice
Clotted red cell Bacterially contaminated platelets
INSPECT – accept or reject?
Step 6: correct patient identification at bedside (prior to transfusion) Conscious patient
Ask patient’s full name and ic no.
Check against wrist band
Ask for blood group type if known
Check patient ID, form, blood unit and PPDK card matches
Unconscious patient Check wrist band Check patient’s
notes/ IC
Check patient ID, form, blood unit and PPDK card matches
Double check by second person
Bedside check
Step 7: monitoring vital signs
Transfuse blood/ components promptly (after correct bedside patient identification)
Check T0, BP and PR prior to transfusion
Re-check vital signs first 15 minutes and ½-1 hourly
Fill PPDK card AFTER completion of transfusion
Return PPDK card with used blood bags to BB
Monitoring vital signs Prior to transfusion Periodically
thereafter
Correct practice at every step from vein to vein
Ensures a safe transfusion
Vein to vein
But what happens when this practice fails?
NEAR MISSES - you’re luckyMEDICO-LEGAL CASES - no way out
Medico-legal issues
Wrong blood – wrong patient
The single most frequent error resulting in ABO-incompatible transfusion is the administration of properly labeled blood to a recipient other than the one intended
Linden JV, 1993
Case 4
50 year-old lady
c/o menorrhagia x 2 years
Hb 5.6
Film: iron deficiency anaemia
Diagnosis:
Menorrhagia 20 to DUB with chronic anaemia
Case 4 – cont’d
O/E: Pale Koilonychia
BP 140/85 PR 78
Chest: clear
No pedal oedema
Case 4 – cont’d
GXM 3 PC requested
2 PC transfused on night of 5th April 2007- uneventful
3rd PC commenced at 0400 on 6th April 2007
After 200mls, c/o headache, breathlessness, nausea and vomiting
Case 4 – cont’d
Blood transfusion stopped
Transferred to ICU
O/E: pale and tachypnoeic
BP 116/68 PR 98 T 400C PO2 75 mmHg
No urine output
Case 4 – cont’d
Diagnosis: Acute haemolytic transfusion reaction
Acute oliguric renal failure
Acute respiratory distress
Disseminated intravascular coagulation
Case 4 – cont’d
Management Ventilatory support Renal support with haemodialysis Blood support
13 units PC 24 units cryo 15 units FFP 26 random and 3 apheresis platelets= 81 donor exposures + 3 (PRBC)
Case 4 – cont’d
Patient survived
Discharged on 27th April 2007
On follow-up 1 year later, mild renal impairment and hypertension
No more menorrhagia
Case 4 – how error happened
HO checked blood and request form at nurses counter
2 patients requiring blood at the same time
HO ticked ✓ and signed checklist form at counter
Case 4 – how error happened
No bedside check done
Nurse in charge did not double check
Patient group O given A blood, the other patient group A given O blood
The verdict – medical negligence
Case awarded a substantial amount
In the news…
Contaminated blood
Wednesday November 14, 2007Ex-teacher awarded RM450,000By EMBUN MAJID
ALOR STAR: A former Quran teacher, who sued the Government over the HIV-contaminated blood she received during a transfusion seven years ago at Jitra Hospital, has been awarded RM450,000.
Case 1
SEGAMAT, JOHOR: Felda settler Norizan Ismail died last Friday, four years after allegedly contracting HIV in hospital.
Norizan, 46, of Felda Palong Timur, is believed to have been infected with HIV during a blood transfusion at Segamat District Hospital. She was later diagnosed HIV-positive.
Case 2
But …
Major risks of transfusion
The major risks of transfusion currently lie in the clinical use of blood in hospitals, rather than with transmission of infectious agents through the supply
Stephen Review 2001
Inappropriate and Unnecessary (I&U) transfusions Hébert et al:
unnecessary transfusions: 4 to 66%
The SANGUIS study: transfusion rates depend more on
physicians than on type of procedure, patient population or hospital
SHOT 1996 – 2011
Back to basics – key lesson
An emphasis again on the importance of the essential steps of the transfusion process: taking the blood sample from the correct patient correct laboratory procedures issuing of the correct component and identification of the right patient at the bedside at
the time of transfusion Identification of the correct patient remains a
key issue and that this must become a core clinical skill
Improving communication & handoverSHOT report 2011
NEAR MISSES TRANSFUSION ERROR
2010 6 3 1
2011 12 2 1
2012 9 7 1
2013 11 5 -
2014 ( till Feb)
2
WARD BLOOD BANK
NEAR MISSES/ TRANSFUSION ERROR HOSPITAL AMPANG 2010-2014 (Feb)
Blood bank data, Ampang hospital
Ampang Hospital (2012)
Transfusion error Error occurred in haematology ward Wrong blood given to patient by new SN No bedside check done Error realised when another SN wanted to
transfuse blood to another patient Patient group B pos, transfused group O pos
blood
7 Steps to a Safe Transfusion
Inappropriate & unnecessary (I&U) transfusions can result in a major transfusion reaction, morbidity and mortality!
Module 6- case 1 (post-partum, iron deficiency anaemia)Module 6- case 3 (dengue fever)Module 7- case 5 (menorrhagia, iron deficiency anaemia)
The next time you decide to transfuse
Stop, think and ask yourself …
Is it really necessary?
The end