Deceptively Low Morbidity from Failure to Practice Safe Blood Transfusion: An Analysis of Serious Blood Transfusion Errors

Abstract

Within a 24-month period, 5 patients in a large teaching hospital were mistakenly transfused with blood that had been crossmatched for different patients. Each of the incidents was due to failure by ward staff to adhere to established safely procedures. Three incidents were entirely due to failure to make the standard checks comparing the identity details on the blood pack label with the patient identification details. The fourth incident was due to a combination of inadequate checking and incomplete patient identification procedure. The fifth incident was due to a series of errors that consisted of inadequate checking, plus putting the wrong patient's blood into the sample tube, plus misspelling of the patient's name on both sample tube and request form. There was no serious morbidity. All of these incidents took place when an unusual coincidence or contributing error lead to unmasked inadequate checking of blood unit against patient's identity by ward staff. The incidence of inadequate checking technique may be much higher than the incidence of erroneous transfusion events. It may be difficult to test the ability of an 'improved' transfusion procedure to prevent disasters from erroneous unit-to-patient matching, since assessment will need to include actual 'worst case' situations, which should be rare.

Clinical use of FFP: results of a retrospective process and outcome audit

“…Audit studies of blood use have identified a number of areas of concern. These arise from system failures, for example inadequate documentation of product use, as well as outcome‐related aspects such as inappropriate administration of products ( Murphy & McClelland, 1989). The hospital population studied in this report comprises most of the acute medical and surgical specialties of large regional hospitals, although it lacks the specialties of cardiac surgery and neonatal intensive care, both of which are traditionally associated with high use of FFP.…”

Errors in blood transfusion in Britain: survey of hospital haematology departments

“…Only a third of unmatched transfusions are incompatible with ABO blood groups; of these, only about a tenth are associated with a fatal outcome 4. We should not, however, be complacent as these figures emphasise that data on mortality and morbidity, even if complete, can give only a substantial underestimate of the incidence of important failures in the transfusion process.…”

Using standardised patients in an objective structured clinical examination as a patient safety tool

“…[17][18][19][20][21] In transfusion medicine, post-donation information accounts for the majority of events reported by blood and plasma centres to the US Food and Drug Administration (FDA) through a mandatory reporting system, the blood product deviation (BPD) report. 22 The FDA further classifies postdonation information into two categories; information that was known or could have been known at the time of donation, and information not known at the time of the donation.…”