June 2010, Vol. 2, Issue 6

Wrong Patient - Wrong Unit:
Preventing Transfusion Errors

Submitted by: Susann Stephenson, RN, JD | Consultant, Risk Management,
Strategic Healthcare Group, LLC

Previous newsletter articles have discussed the importance of appropriate transfusion decisions as a critical element of transfusion safety, as well as the role of bedside nursing as vigilant advocates during the transfusion administration process. This month's article focuses on the technical and regulatory aspects of avoiding transfusion errors through the prevention of pre-analytical mistakes, bedside identification errors, and the use of event reporting systems.

One of the most serious risks of blood transfusion is an ABO incompatible transfusion or mistransfusion. In 1999 The Joint Commission (TJC) identified mistransfusion as a sentinel event and suggested strategies for reducing transfusion risks. Unfortunately, in 2008 TJC reported 18 transfusion related sentinel events, the highest number reported for any year since TJC began reporting in 1995. Utilizing hospital event reporting systems (ERS) to document mislabeled blood samples and transfusion related adverse events will help prevent mistransfusion sentinel events.

Despite TJC mandates that blood samples be labeled in the presence of the patient, a recent study found that patient misidentification was associated with 88% of pre-analytic laboratory events, largely due to mislabeling during the process of specimen collection. Current laboratory practices of rejecting erroneously labeled specimens without documenting the occurrence provides no opportunity for process improvement. Until such time that technology eliminates opportunities for errors related to sample mislabeling, the ERS should be used to analyze hese events and reduce recurrence.

Just as other types of undesired events in hospitals are subjected to analysis and trending, when an incorrectly labeled sample arrives in the lab there is potential for patient harm and the incident should be subjected to an investigation with appropriate process improvement, staff re-education, and/or retraining. Samples for type and cross match or type and screen that reach the lab with an incorrect label must be subjected to root cause analysis as a potential sentinel event. When the lab representative simply asks the phlebotomist to redraw a mislabeled sample there is no opportunity to learn from the error and correct the system that allowed the error to occur.

The incidence of transfusion errors from patient misidentification is 1: 16,000 - 19,000. The two person verification procedure for transfusions is prone to "become lackadaisical, in essence a rubber stamp, thereby providing false reassurance rather than truly increased safety." Real time, random surveys of patient identification and transfusion verification procedures should be conducted in all clinical areas that provide transfusions and reported through process improvement systems to help ensure truly independent double checks that promote transfusion safety.

Finally, the procedures used by clinicians for reporting a transfusion reaction or adverse event must incorporate risk management notification. Subjecting that all transfusion related adverse events (including near misses) to appropriate risk review, investigation, and root cause analysis is an essential element for improving transfusion safety.

Healthcare risk management programs have the tools necessary to support transfusion safety initiatives; however event reporting systems and random clinical practices surveys are seldom utilized to improve sample labeling accuracy and patient identification and transfusion verification procedures. Incorporating established event reporting systems and patient safety initiatives into transfusion oversight is essential for preventing mistransfusion.

Selected References:

Goodnough LT, Risks of Blood Transfusion, Critical Care Med, 31:S678-S686, 2003.

The Joint Commission Sentinel Event Alert no. 10, Blood Transfusion Errors: Preventing Future Occurrences, August 30, 1999.

http://www.jointcommission.org/NR/rdonlyres/67297896-4E16-4BB7-BF0F-5DA4A87B02F2/0/se_stats_trends_year.pdf visited 05/01/2010.

The Joint Commission National Patient Safety Goal no. 1, Improve the Accuracy of Patient Identification, first published in 2002. The first 2008 Laboratory Services National Patient Safety Goal requires that processes are established to maintain a sample's identity in the pre-analytical, analytical, and post-analytical processes. Joint Commission Perspectives, 27(7):10-22; July 2007.

Dunn EJ, et al, Patient Misidentification in Laboratory Medicine: A Qualitative Analysis of 227 Root Cause Analysis Reports in the Veterans Health Administration, Arch Pathol Lab Med, 134:244-255, Feb. 2010.

Goodnough LT, Risks of Blood Transfusion, Critical Care Med, 31:S678-S686, 2003.

Wachter RM, Understanding Patient Safety, p. 47, McGraw-Hill, 2008.

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