Don’t assume, verify: how to halt transfusion errors

Giving the wrong blood can be fatal, but stricter routines and electronic tracking are helping to reduce the hazards of transfusion

Giving the wrong blood can be fatal, but stricter routines and electronic tracking are helping to reduce the hazards of transfusion

Picture: Science Photo Library

Having a blood transfusion has probably never been safer, but this has only been achieved with constant vigilance by all involved.

A transfusion involves nine steps, often with a different healthcare professional involved in each one. There are numerous opportunities for errors, the consequences of which can be fatal.

These errors are analysed each year in the annual Serious Hazards of Transfusion (SHOT) report. Over the past 20 years this has looked at the changing picture of safety in blood transfusion, with some issues rising in importance and others diminishing.

Reducing harm

But the role of healthcare professionals in reducing harm remains vital. Around 85% of the incidents reported to SHOT are errors, usually involving not just one failure but a chain of unusual events. Human factors are key in many of the errors – but it is also the vigilance and methodical approaches of staff that stop other errors occurring.

‘Each one of the nine steps can be done by a different healthcare professional,’ says Paula Bolton-Maggs, medical director of SHOT. ‘It is really important that nursing staff do their own step correctly and don’t assume that the step before them has been done correctly.’

Drawing a parallel with aviation, she says a pilot, however experienced and competent, would not take off until safety checks had been completed. The same should be true of the final bedside check before a transfusion.

‘Wrong blood in tube’

Patient blood management practitioner at NHS Blood and Transplant and SHOT Jayne Addison says nurses may be involved at various steps along the path to transfusion, including taking blood samples and sending them to the laboratory, collecting blood components from the transfusion laboratory and carrying out transfusions on the ward. She says nurses can help reduce the number of errors.

One of the most common errors is what is known as ‘wrong blood in tube’, where the wrong name is written on the tube the blood goes into when it is taken. This has implications not just for transfusions but for all cases where blood tests play a part in diagnosis, yet it happens surprisingly often.

Ms Addison says it is important to take blood samples at the bedside, and to take one sample at a time then label it and send it to the transfusion laboratory. Then repeat the process for the second sample, if required.

Explain the rationale

‘But we know that clinical staff tend to take two samples at the same time then write different times on the labels,’ she says, adding that if the process is interrupted, the tests should be repeated. Patients are usually accepting of this if the rationale is explained.

Nurses can also be involved in collecting blood for transfusion, another area where errors occur. ‘It is amazing how many people collect the wrong blood from the fridge and then deliver it to the ward. If it is not then checked, it may be given to the wrong patient,’ she says.

Then there is the transfusion itself, which can sometimes occur in a highly pressured environment such as an emergency department, and is the last chance to spot a mismatch between the patient and the blood they are receiving. ‘Stop for a moment – it could save a life,’ says Dr Bolton-Maggs.

Transfusion risks to be aware of

The public may see infection as the main risk from a transfusion, but the chances of that are vanishingly small – just one serious case in the most recent SHOT report. 

Paula Bolton-Maggs: Don’t assume
the previous step was correct.

But there are other risks that healthcare professionals need to be aware of when assessing patients for transfusion, and once the transfusion has been given.

Reactions can occur once transfusion has started, so having baseline observations from before the transfusion and 15 minutes in is important, says Paula Bolton-Maggs, medical director of SHOT.

Most common complications

One of the most common post-transfusion complications is transfusion-associated circulatory overload (TACO). This is more common in older patients with comorbidities, and is the most commonly reported cause of transfusion-related mortality and major morbidity.

Unfortunately, few patients are identified as at risk in advance of transfusion: five of the seven patients who died from TACO last year had risk factors for circulatory overload. Having accurate recordings of a patient’s weight, fluid balance and vital signs is important, and suspected TACO cases need rapid clinical assessment.

Bedside checklists

Bedside checklists to ensure that the patient’s details match those of the intended recipient are part of this last line of defence. The first SHOT report 20 years ago called for this, and last year England’s chief medical officer Dame Sally Davies and chief nursing officer Jane Cummings issued an alert on safe transfusion practice re-iterating the importance of checklists.

However, a survey carried out by SHOT in January suggested that around 20% of the 160 trusts and health boards who responded did not use a checklist, although most were planning to implement one, and 22% were in the process of implementing one.

But even the best designed processes can fail if those involved become distracted. Dr Bolton-Maggs describes interruptions and distractions as ‘our biggest risk.’

SHOT report for 2017

  • 1 case where ABO-incompatible red cells were transfused (patient survived)
  • 21 deaths where transfusion was implicated, 14 of which were potentially preventable
  • 112 cases of major morbidity
  • 307 incorrect blood components transfused
  • 789 ‘wrong blood in tube’ mistakes

Ms Addison says: ‘Our message would be that it does not matter how experienced you are, if you become distracted or are interrupted errors will still occur.’

Do not disturb

There is a parallel with drug administration, where there are also many opportunities for errors that could harm patients. Nurses doing drug rounds now have tabards to mark them out and ensure they are not disturbed, and it would be possible to put something similar in place for nurses taking and administering blood.

Most healthcare professionals will be aware of the danger of giving incompatible red blood cells, which can lead to the sudden death of a patient and is a ‘never event’ – one of the scenarios that are never meant to happen in healthcare.

‘We have seen a reduction in red cell ABO-incompatible transfusions over the years, but we can’t think we have cracked it because we haven’t,’ says Ms Addison, referring to the ABO blood group system.

Confusion over names

Although transfusion of ABO-incompatible red cells only happened once last year, there have already been incidents reported this year. In 2016, a nurse was found guilty of manslaughter when she transfused AB blood into a patient who was blood group O, following confusion about patients’ names.

Other blood components also need to be compatible with the patient’s blood, an area where nurses may be less knowledgeable. Ms Addison believes there is a place for more education, probably early on in a nurse’s career, so they are more aware of the risks with other components of blood.

Jayne Addison: If you are distracted
or interrupted errors will occur. 

She acknowledges this can be challenging for nurses, who may only be involved in a handful of transfusions a year, so there is a need to get certain key messages across. She suggests that just stopping and asking what is going on can help, for example when being given a blood component that doesn’t match exactly the patient’s blood group.

Human factor

Technology can also help reduce errors. Electronic barcoding of blood, for example, makes it easier to check it is the right blood being given to the right person (see box below).

But human factors still interplay with technology, and sometimes staff will override or not use such systems. Nonetheless, the potential benefits of such ‘vein-to-vein’ systems are significant, and one of the recommendations of the SHOT report is that hospitals should consider investing in them.

So what are the key messages for nurses coming out of the SHOT report? Dr Bolton-Maggs sums it up: ‘Do your own job well. Do not assume, verify. And do not take short cuts on transfusion, because it can be disastrous.’

Electronic tracking can make it easier

Oxford University Hospitals NHS Foundation Trust has seen errors fall since it introduced an electronic blood tracking system just over ten years ago.

The BloodTrack system, which the trust helped to develop, involves 230 handheld devices across the trust that are used at the bedside to positively identify patients and produce labels for their blood samples.

At the other end of the process, it will scan blood that is about to be transfused and ensure that it matches the patient’s identity band. An audible alarm sounds if the two don’t match. Blood can also be automatically dispensed from a fridge using similar identification processes. Some of the electronic processes will reduce the need for additional staff checks.

Audit trail

Since the system was introduced, wrong blood in tube errors in transfusion cases have been hugely reduced – from one in 12,322 cases to one in 26,690. Adherence to the correct patient identification steps at the bedside has also improved, from 11.8% to an impressive 100%, and tracking means less blood is wasted, as it is clearer how long it has been out of the fridge.

Where errors are detected there is an ‘audit trail’ of who was involved, as staff have to scan their identification card throughout the process. The focus is on retraining and the use of reflective accounts as part of a ‘no blame’ approach, where possible.

‘BloodTrack is such a valuable tool in preventing errors and helping staff do the right thing,’ says the trust’s project development manager for the blood safety and conservation team Sophie Staples. ‘We say make the right thing the easy thing to do.’

Alison Moore is a freelance health journalist

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