Incorrect blood component transfused (IBCT)

Notes

1. QLD data is unavailable for 2012–13.
2. Sex and facility location data is unavailable for NSW.
3. Time of transfusion data is unavailable for NSW and SA.
4. Data is unavailable for WA.
5. Uncategorised refers to those reports where no data was provided.

IBCT occurs when a patient receives a blood component intended for another patient or a blood component where special requirements (such as CMV‑negative or irradiated component) are not met. It should be noted that adverse events attributed to transfusion of ABO incompatible components are included in this category. Such events could equally be described as acute haemolytic transfusion reactions, but are included here because the key failure is IBCT. Transfusion of ABO incompatible components to a patient is considered a 'sentinel event' and is also subject to other reporting requirements.

From 2011–12 to 2012–13:

• There were 105 reports of IBCT to the National Haemovigilance Program, accounting for 10.1% of all reports (1,044) for this period.
• The number of cases dropped in 2012–13 due to the unavailability of QLD data.
• The majority of cases were related to red cell transfusion.
• The majority of cases (85 out of 105) were not assessed for imputability scores and NSW reported most of the cases (82).
• The life threatening case reported in 2012–13 was confirmed to be related to the transfusion of red cells.

Notes

1. Outcome severity and imputability data unavailable for QLD for 2012–13.
2. Outcome severity and imputability data unavailable for WA.

Table 14 details the contributory factors for reported IBCT events for 2008–09 to 2012–13:

• In 2008–09, 'prescribing/ordering' was the most frequent factor that contributed to IBCT adverse events.
• For 2009–10 and 2010–11, the most frequently cited contributory factors were 'prescribing/ordering', 'specimen collection/labelling', 'administration of product', and 'procedure did not adhere to hospital transfusing guidelines'.
• For 2011–12 and 2012–13, the most frequent factors that contributed to IBCT events were 'laboratory (testing/dispensing)' and 'indications did not meet hospital transfusion guidelines'.

This reported data highlights the range of problems that contribute to IBCT events, and the key observation for IBCT is that staff should conform to local facility guidelines for prescribing, labelling, laboratory testing and transfusing.

Haemovigilance data and clinical studies cite three major areas of human error that jeopardise safe transfusion:

• accurate patient identification and proper labelling of pre‑transfusion specimens
• appropriate decision‑making regarding the clinical use of blood components
• accurate bedside verification that the correct blood is to be given to the intended recipient.

The SHOT UK scheme showed that approximately 70% of IBCT event errors took place in clinical areas, the most frequent error being failure of the final patient ID check at bedside.

IBCT represents failure of the hospital system, which needs to be identified and subsequently corrected to prevent similar events happening in the future. For this reason, the recent Standard 7 Blood and Blood Products of the National Safety and Quality Health Service Standards (NSQHS Standard 7) states that adverse blood and blood product incidents should be reported to and reviewed by the highest level of governance in the health service organisation. The Australian Haemovigilance Report 2013 delivered several recommendations on reducing human errors:

• Clinical staff should comply with the national guidelines on sample collection and administration of blood and blood products.
• Develop tools to encourage alignment of prescribing practice with clinical guidelines.
• Promote the application of technical adjuncts such as portable barcode readers and/or radio-frequency identification scanners to reduce the scope for error.

The case study below demonstrates:

• an IBCT can occur as result of a series of process failures
• the multi-disciplinary nature of the transfusion process and the importance of education across all disciplines
• the importance of adhering to health service policy and procedures at all times
• 2D barcoding and patient safety software can reduce human errors.

Case study 2: Incorrect blood product was given to patient due to a series of process failures

Description

A 96 year old man was admitted with a fractured neck of femur, scheduled for surgery that afternoon. The patient's international normalised ratio (INR) was elevated at 1.6, and the decision was made to treat this elevated level with a unit of FFP prior to surgery.

The medical officer (MO) went to the laboratory to collect the unit of FFP. On arrival the scientist pointed to where the FFP was located and requested the MO to sign the unit out of the laboratory in the blood register. The unit collected by the MO was allocated for another patient and labelling not yet completed. The MO signed the unit out against his patient details in the blood register without checking the product details matched. He then took the unit to the ward.

On return to the ward the MO handed the FFP to the nurse caring for the patient, who was unaware of the request for transfusion. The nurse noted the lack of paperwork accompanying the FFP and sent the patient services attendant (PSA), with the unit, back to the laboratory to collect the appropriate paperwork.

The PSA returned and stated that there was no paperwork for this FFP unit and that it did not need to be checked, although the laboratory staff stated they did not speak to the PSA regarding the FFP.

The nurses on the ward took the word of the PSA that they did not need the paper work, and checked the FFP to the patient. The unit was group O, the patient's blood group was group A, therefore making this an incompatible transfusion. The staff were unaware of this at the time as both medical and nursing staff were under the impression that O was the universal group for FFP as well as red cells.

Later the laboratory staff noted the FFP for the patient was still in the fridge and when they checked the register realised the error. They immediately rang the ward; however the product had already been administered.

As a result the patient had a mild rise in bilirubin, and his procedure was delayed as a precaution and to monitor the patient for further sequelae.

Recommendations from the health service

• All staff who collect blood and blood products from the laboratory must be trained and have knowledge of correct processes for blood collection, including taking appropriate documentation to identify the patient and the product required.
• Staff collecting blood and blood products must collect from the collection fridge where all products are labelled and ready for collection, and not collect directly from the laboratory.
• Education of all medical and nursing staff regarding the appropriate use of FFP and the compatibility of blood groups for FFP, including the use of I-transfuse factsheet 'I need to know about Fresh Frozen Plasma' http://www.transfusion.com.au/fact_sheets.

Summary

This case study demonstrates that serious errors often occur as a result of a series of process failures rather than a single event failure. It also demonstrates the multi-disciplinary nature of the transfusion process and the importance of education across all disciplines. This event also highlights the importance of adhering to health service policy and procedures at all times.

The use of patient safety software and 2D barcoding to identify patient and product can also assist in the reduction of errors in which mis-identification of either the patient or the product occurs and should be considered in all areas involved in transfusion.