Human errors in manual techniques for ABO/D grouping are associated with potentially lethal outcomes

Mistry, H; Poles, D; Watt, Alison

doi:10.1111/tme.12616

Cited by 7 publications

(6 citation statements)

References 15 publications

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“…[25][26][27][28][29][30][31] Moreover, WBIT is more likely to occur among mislabeled samples, which emphasizes the need for laboratories to reject patient samples with even minor labeling errors to reduce the risk of ABO-incompatible RBC transfusions. 20 Finally, Mistry et al 32 analyzed laboratory techniques reported in SHOT data from 2004 to 2016, and found that manual intervention was the cause of nearly all (93%) ABO/D typing errors; in contrast, there were no errors when full automation was used. The authors concluded that where manual testing cannot be avoided, results should be confirmed by automated techniques as soon as possible, and a backup process should be available at all times.…”

Section: Discussionmentioning

confidence: 99%

Trend in ABO‐incompatible RBC transfusion‐related fatalities reported to the FDA, 2000‐2019

2020

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Background: ABO-incompatible red blood cell (RBC) transfusions and acute hemolytic reactions occur infrequently, yet resultant fatalities are reported to the US Food and Drug Administration (FDA) every year. We describe a 20-year retrospective study of reported mistransfusion cases to identify temporal trends, common causes, and corrective actions taken to prevent recurrence. Study Design and Methods: ABO-incompatible RBC transfusion-related fatalities reported to the FDA in 2000-2019 were reviewed for patient demographics, primary attributed cause, contributing factors, and corrective actions. Results: Eighty reported deaths after ABO-incompatible RBC transfusion occurred in the 20-year period. A decrease in the number of cases after 2008 was sustained through 2019 (mean 6 cases/y, 2000-2009 vs 2 cases/y, 2010-2019). The estimated rate of reported mistransfusion fatalities was 1 per 2 million RBC units transfused in 2000-2009 and 1 per 7.14 million RBC units in 2010-2019 (P < .0001). Administration errors (wrong patient or wrong unit transfused) and sample collection errors (wrong blood in tube [WBIT]) significantly decreased over time but remained the most common causes. In all WBIT cases, verification of patients' ABO type with a second sample or historical type was not performed before transfusion; 16 of 19 (84%) institutions that reported corrective actions subsequently instituted this requirement. In the other categories, 22 of 58 (38%) facilities reported plans for technological process improvements, such as electronic patient identification. Conclusions: The rate of reported fatalities from ABO-incompatible RBC transfusion has significantly decreased in the past decade. Still, about two cases are reported each year, highlighting gaps in best practices and areas for improvement. K E Y W O R D S RBC transfusion, transfusion complications-noninfectious, transfusion practices (adult) 1 | INTRODUCTION Transfusions of ABO-incompatible red blood cells (RBCs) have long been considered preventable errors that should never occur, yet resultant acute hemolytic transfusion

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Section: Discussionmentioning

confidence: 99%

Trend in ABO‐incompatible RBC transfusion‐related fatalities reported to the FDA, 2000‐2019

2020

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“…First, we consider the human factors involved [ 22 ]. We explored the reasons why Nurse A believed that the blood bag in her hand belonged to Patient X and not to Patient Y.…”

Section: Missed Opportunitiesmentioning

confidence: 99%

“…Human behavior is the result of a combination of human and environmental [20] or the SHELL model [21]. Figure 1 First, we consider the human factors involved [22]. We explored the reasons why Nurse A believed that the blood bag in her hand belonged to Patient X and not to Patient Y.…”

Section: Missed Opportunitiesmentioning

confidence: 99%

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery

Uramatsu

Maeda

Mishima

et al. 2022

J Cardiothorac Surg

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Background The past half century has seen the near eradication of transfusion-associated hazards. Intraoperative cell salvage while widely used still poses significant risks and hazards due to human error. We report on a case in which blood collected from a patient with lung cancer was mistakenly administered to a patient undergoing cardiac surgery who should have received his own collected blood. The initial investigation found that the cause of the patient harm was violations of procedures by hospital personnel. A detailed investigation revealed that not only violations were the cause, but also that the underlying causes included haphazard organizational policies, poor communication, workload and staffing deficiencies, human factors and cultural challenges. Case presentation On August 14, 2019, a 72-year-old male was admitted to our hospital for angina pectoris and multivessel coronary artery disease. Cardiac surgery was performed using an autologous salvage blood collection system, and there were no major problems other than the prolonged operation time. During the night after the surgery, when the patient’s blood pressure dropped, a nurse retrieved a blood bag from the ICU refrigerator that had been collected during the surgery and administered it at the physician's direction, but at this time neither the physician nor the nurse performed the required checking procedures. The blood administered was another patient's blood taken from another surgery the day before; an ABO mismatch transfusion occurred and the patient was diagnosed with DIC. The patient was discharged 65 days later after numerous interventions to support the patient. An accident investigation committee was convened to analyze the root causes and develop countermeasures to prevent a recurrence. Conclusion This adverse event occurred because the protocol for intraoperative blood salvage management was not clearly defined, and the procedure was different from the standard transfusion practices. We developed a new workflow based on a human factors grounded, systems-wide improvement strategy in which intraoperative blood collection would be administered before the patient leaves the operating room to completely prevent recurrence, instead of simply requiring front-line staff to do a double-check. Implementing strong systems processes can reduce the risk of errors, improve the reliability of the work processes and reduce the likelihood of patient harm occurring in the future.

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“…Errors can be reduced by eliminating human interventions. The introduction of fully automated systems in the laboratory resulted in reduction in errors compared to manual techniques (Mistry et al , ) and is a recommended standard (Chaffe et al , ). There is now good evidence that expanding electronic identification systems (EIS) for the full vein‐to‐vein (V2V) transfusion process also improves safety and reduces human error (Dzik et al , ; Murphy & Kay, ; Callum et al , ; Kaufman et al , ).…”

Section: Serious Pathological Complications Of Transfusion — Can Theymentioning

confidence: 99%

Transfusion errors — can they be eliminated?

Watt¹

2019

Br J Haematol

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Summary The Serious Hazards of Transfusion haemovigilance scheme has documented adverse transfusion incidents for 22 years. Transmission of infection (three in 2018), transfusion‐related lung injury (one in 2018) and transfusion‐associated graft‐versus‐host disease (none since 2012) are rare. Despite national recommendations, guidelines and protocols, most incidents more than 85% of incidents are still due to errors in the transfusion process. European regulation and mandatory competency assessments have been associated with a reduction in ABO‐incompatible transfusion, but errors continue to put patients at risk. What can be done? Errors are reduced by the use of electronic identification systems. Exploration of human factors and ergonomics (HFE) results in amended approaches away from blaming individuals to a full review of the systems and environment. Research examining how transfusion is performed (work‐as‐done) compared to work‐as‐imagined (set out in protocols and guidelines) discovers where variability results in either resilience or error. All staff require HFE training, but this should be alongside employment of suitably qualified and experienced HFE professionals. Good teamwork is key and is undermined by insufficient staffing and poor morale. The five choosing wisely recommendations for transfusion (to ensure appropriate use) need to be widely disseminated to medical staff in all specialties to ensure patients participate in the decision‐making.

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Human errors in manual techniques for ABO/D grouping are associated with potentially lethal outcomes

Cited by 7 publications

References 15 publications

Trend in ABO‐incompatible RBC transfusion‐related fatalities reported to the FDA, 2000‐2019

Trend in ABO‐incompatible RBC transfusion‐related fatalities reported to the FDA, 2000‐2019

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery

Transfusion errors — can they be eliminated?

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