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Blood Transfusion Error Prevention - Nurses Role

This document discusses the role of nurses in preventing blood transfusion errors. It notes that transfusion errors can occur due to administrative mistakes like labeling samples incorrectly or transfusing the wrong blood type. The document outlines several specific errors that commonly occur due to nurse negligence, such as mislabeling samples, ordering blood for the wrong patient, or failing to monitor patients after transfusion. It emphasizes that nurses have an important role to play by carefully checking patient identification against blood samples before transfusion. New technologies like barcoding and training programs can help nurses reduce errors. Overall, the document stresses that establishing clear policies, ongoing education, and close monitoring are needed to ensure nurses can safely perform blood transfusions and prevent errors.

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Lorenn Adarna
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151 views

Blood Transfusion Error Prevention - Nurses Role

This document discusses the role of nurses in preventing blood transfusion errors. It notes that transfusion errors can occur due to administrative mistakes like labeling samples incorrectly or transfusing the wrong blood type. The document outlines several specific errors that commonly occur due to nurse negligence, such as mislabeling samples, ordering blood for the wrong patient, or failing to monitor patients after transfusion. It emphasizes that nurses have an important role to play by carefully checking patient identification against blood samples before transfusion. New technologies like barcoding and training programs can help nurses reduce errors. Overall, the document stresses that establishing clear policies, ongoing education, and close monitoring are needed to ensure nurses can safely perform blood transfusions and prevent errors.

Uploaded by

Lorenn Adarna
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Blood Transfusion Error Prevention - Nurses Role

Blood Transfusion Error


Transfusion of blood saves life. An error in blood transfusion, at the same time, takes
life. Blood samples can be autologous, in which the patient’s own blood is collected
before surgery for possible use during or after surgery or allogenic, in which the blood is
collected from donors. Clinical demand for blood is perennial and transfusion errors are
accountable. This accountability of transfusion errors comes to light with the numerous
reports on total blood transfusion errors. The discovery that HIV could be transmitted by
blood transfusion in 1982 has given rise to strict regulations on blood donation and
screening procedures. Apart from HIV, HBV and HCV risks have also been well
addressed in blood transfusion process.

In spite of such strict clinical measures on blood transfusion, there are certain areas in
transfusion process which requires acute attention. For example, the fatal acute
hemolytic reactions to transfusion caused by ABO incompatibility have been attributed
to administrative errors. The mismatch of blood units with that of the patient blood as a
result of negligence is a serious cause of patient fatality. Apart from ABO incompatibility,
contamination of red cells especially of bacterial origin is a matter of concern. Yersinia
enterocolitica is a common organism found to cause contamination of red cells (Carson
et.al, 1999). The infection of such organisms seems to be related to the storage period
of blood units. Contamination of platelets is another serious cause where
Staphylococcal infection is very common. Klebsiella and Serratia have also been
detected in platelet contamination. Transfusion related acute lung injury is an acute
respiratory distress occurring within hours after transmission, usually characterized by
hypoxia due to pulmonary edema.

Error Prevention – Nurse’s Role


Nurses being responsible for the final bedside check before transfusion, have the final
opportunity to prevent a mis-transfusion (Mole et.al, 2007). Blood products most often
transfused by nurses include packed red blood cells, fresh frozen plasma, and platelets
(Simmons P, 2003). An understanding and knowledge of the pathophysiology of
transfusion reactions, symptoms and treatment is essential to safely administer and
monitor transfusions (Labovich, 1997). A Failure Mode and Effect Analysis (FMEA) on
the blood transfusion process to reduce the risk of problems inherent in the procedure
has been developed recently to aid nurse decision making in the transfusion process
(Burgmeier , 2002).Measures have been developed to analyze results and FMEA has
been a valuable tool for error-trapping in the blood transfusion process. Transfusion
error, resulting in the patient receiving the incorrect blood component, remains the
largest risk related to transfusion. Nurses can increase compliance in high-risk areas of
the
transfusion process and reduce the potential for errors by developing accessible blood
transfusion policies, auditable performance standards and training, and educational
initiatives (Gray et.al, 2005).A Study to assess the effect of a simple intervention in the
form of a tag on blood bags positioned in such a way that the nurses required to remove
the tag to spike the unit reminding nurses to check the patient's wristband has shown
that such a simple intervention is ineffective and there is a need for more stringent
practice guidelines for the nurses (Murphy et.al,2007). Recently published guidelines
highlight that most serious transfusion complications occur within the first fifteen
minutes of transfusion and a close monitoring has been recommended before and
fifteen minutes after commencement of each unit of blood (Rowe et.al,2000).The
guidelines also recommend careful monitoring in the areas of sample collection, pre-
administration checking to avoid adverse reactions (Hainsworth,2000).

The blood transfusion errors that often occur due to negligence of nurses include the
following:
1. Samples being mislabelled with another patient’s identity.
2. Blood being ordered for wrong patient.
3. Other blood components being ordered for wrong patient.
4. Blood sample being taken from wrong patient.
5. Patient given Rh D+ stock from the trauma refrigerator when Rh D- available.
6. Patient being transfused with un-irradiated blood.
7. Albumin being transfused to wrong patient.
8. Autologous blood being discarded because of nurse’s failure to monitor patient
for 4 hours and IV set not infusing.
9. RN returning blood to OR refrigerator after being kept in the theatre for 12+
hours.
10. RN leaving a unit of group B Rh D+ blood in trauma refrigerator for 12+
hours.
11. Unit of RBCs missing from the OR refrigerator with no record of transfusion of
the unit (Callum et.al, 2001).

The prompt reporting of near-miss events of transfusion errors to improve transfusion


safety has been elucidated in this study (Callum et al., 2001).The blood transfusion
errors often includes administration of blood to wrong recipient, phlebotomy errors &
blood bank errors including testing of wrong specimen. The most important of all errors
has been the failure to detect at the bedside before transfusion of the wrong unit
(Linden et.al, 2000). A recent study has identified 1.Patient misidentification. 2.
Preliminary diagnostic errors and 3.Final diagnostic errors (Nakleh et.al, 1998) in blood
transfusion.

A lack of awareness of good transfusion practice has been identified as a reason for
poor compliance (Parris, 2007). A bar code patient identification system involving a
hand-held

computer for sample collection and for compatibility testing has been successfully
evaluated recently (Turner et.al, 2003) to help nurses during blood transfusion. A
decentralized phlebotomy skills Programme (Needham, 2001) and cross training in
patient care skills on the nursing units has been found to be effective with reduction in
errors of collection and labelling. Studies have proved that the effective and safe
transfusion of blood depends on a series of linked processes and the safety measures a
nurse should follow for blood transfusion includes donor selection and exclusion, post
collection processing such as leuco-depletion and viral inactivation and neo
technological innovations like the bar-code on the wrist band of each patient (Regan
et.al, 2002).
Recent guidelines for blood transfusion direct that blood should not be transfused
prophylactically and the threshold of transfusion is a hemoglobin level of 7.00 to 8.00
gm per deciliter. The safety directions include selection of donors; heat treatment;
solvent and detergent treatment; methylene blue addition; leucodepletion; irradiation;
minimizing donor exposure and the use of American plasma and Recombinant
products(Goodnough et.al, 1999).Though viral inactivation of cellular products is not
possible with heat, pooled plasma products can be pasteurized at 80° c for 72 hours.
Solvent treatment can be applied to pooled plasma of up to 1000 donations. Methylene
blue and ultraviolet B radiation can inactivate viral products and thus addition of
methylene blue to single units of plasma followed by subsequent irradiation gives the
advantage of not pooling the plasma. Modern leucocyte filters reduce the leucocyte
count to less than 1x106. Leucodepletion seems to reduce nvCJD risks too
(Shaughnessy, 2000).

Conclusions
Published literature throws light on the consequences of blood transfusion errors and
the element of human error involved in such wrong transfusions including administration
to wrong recipient, phlebotomy errors, testing of wrong specimen and failure to detect at
the bedside before transfusion of the wrong unit. A nurse, by profession has
opportunities to establish policies and procedures, design nursing practices, and
educate staff to help avoid blood transfusion errors (Bryan, 2002). There is an urgent
need of training programs in nursing units that educate nurses on blood transfusion risk
reduction, latest safety guidelines, nurse interventions and decision making. There is
also a need for the nurses to be aware the recent advances and technological
innovations in planning and management of transfusion medicine (Nagarajan et.al,
2002). Evidence based clinical guidelines for individual blood components, transfusion
monitoring systems and quality assurance programs are vital to prevent blood
transfusion errors.

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