Transfusion Errors

[mrmic 48]

Would there be any interest having a topic area to share transfusion error stories?   I thought it might be useful for Supervisors, QA and other transfusion services staff to hear accounts of problems that have occurred in other hospitals.  It could help with training laboratory, nursing and medical staff.  It could be lab error, patient ID error, transfusion error, donor center error, etc...  No specific person, hospital, blood center identification, state or country ID.

Or is there some taboo about putting this info out there?  If there is, we could say it is research for a new TV series.......

If there is no interest that's fine too, no worries.

[John C. Staley 1,162]

I especially like the way you phrased it as "transfusion error stories" and not transfusion horror stories.  Looking back I sometimes think I could write a book on the subject.  Well, maybe not a book but at least a novella!  Some of the stories would be comical and others terrifying.  Luckily, in over 35 years in the business none of my stories are fatal but a few had the potential.

 

[Malcolm Needs ★ 4,878]

In the UK, we have the SHOT Report (Serious Hazards of Transfusion) that reports every year, and has done so since 1996.  Their reports, which anonymise the reporter, are always both interesting and informative.

[mrmic 48]

SHOT report sounds a little "official".    Although I'm not suggesting that serious hazards of transfusions not be reported as required, there are some events that sometimes remain "in-house".  Having been in BB 40 years and worked for various transfusion services and few Immunohematology Reference labs for other hospitals there are some interesting stories to tell.  Some may be helpful to facilities with newer TS or QA management.  Some may be a little comical, some scary and some shedding some positive light on the lab saving the day.  Just thought it would be an interesting topic to read through and I'm sure everyone could share something.

Except for CSI, most series are nurses or doctors saving the day or coming to the lab and doing the testing (haha).

[Malcolm Needs ★ 4,878]

Oh, don't get me wrong.  I think it is a splendid idea because, as you so correctly say, people can learn from these things (even people with huge experience), but, believe me, SHOT is far from "official" in terms of people not reporting to it.  Actually, just the opposite has happened, and more and more people are, if you like, "owning up", because there is an absolute trust that there is a "no name, no blame" culture, as far as SHOT is concerned (the actual reporting laboratories may have a "proportional blame" culture if, for example, an SOP is ignored, but SHOT is totally "no name, no blame" as far as the individual is concerned).

[mrmic 48]

Ok, I'll start.  The story of "Who turned off the Light".

The year was 1999.  Hospital "Notme Medical Center" supported an outpatient clinic for patients requiring transfusion, some due to sickle cell anemia.  Often these were young adults that came into the clinic very early in the morning.  After their blood was collected and they were waiting for the crossmatched packed red cell units to arrive, the patients preferred to sleep (pre i-phone years).  Normally at least one light was left on, usually the bathroom light, while they were waiting.  At 0530 the first of two tagged crossmatched compatible group O RH Positive red cell units was verbally crosschecked with the nurse Jane at the transfusion service door to be taken directly to patient Smith's  room for transfusion.  At 0625 the first of two tagged crossmatched compatible group B  RH Positive red cell units was verbally crosschecked with nurse Kathy at the transfusion service door to be taken directly to patient Brown's room for transfusion.   At 0633 nurse Kathy called the transfusion service to see if she could return the blood for patient Brown since someone had already started the first one.   What! Said the BB technologist, the one I just checked out with you was the first unit for patient Brown.

Follow-up:  Nurse Jane had crossed checked the tagged red cell unit for patient Smith with another nurse at the nurses station and it was for a sickle cell patient in room 123 bed A.   She went to the room she normally has gone to in the past, and when she looked into the room, although the lighting was low it was enough to see it was a young adult black patient in the room in bed A.  Although a little groggy, the patient confirmed she was expecting the transfusion.  After starting the unit, the patient appeared to tolerate the transfusion well and the nurse left the room.   After speaking with the BB tech about returning the unit for patient Brown nurse Kathy went back to the room and discovered patient Brown was in bed A and had a red cell unit almost completely transfused but was unit was tagged for patient Smith.   Patient Smith was in bed B.   Both patients were young black adults but had switched beds because patient Smith did not want to be in the bed close to the door.  Luckily the group O unit was compatible with patient Brown and was tolerated well by the patient.

Needless to say, we required Nursing Education Services to review policies regarding the importance of patient identification and cross checking the tagged unit with another nurse at the bedside NOT at the nurses station.  A poor practice that seemed to pop up once in awhile.

 

 

 

[John C. Staley 1,162]

I had always found it difficult to convince nurses that we were working with a person/patient and not a room/bed!  This became even more difficult after all the privacy rules and regulations came about.  It was almost as if they were terrified to say a patient's name aloud!

[MAGNUM 97]

On 2/21/2021 at 9:56 AM, John C. Staley said:

I had always found it difficult to convince nurses that we were working with a person/patient and not a room/bed!  This became even more difficult after all the privacy rules and regulations came about.  It was almost as if they were terrified to say a patient's name aloud!

I have even gone so far as to tell the nurse taking care of the patient that when they learned the patient's name and not the room number to give me a call back and we will discuss the patient at that time.

 

[David Saikin 1,420]

We all have these transfusion event stories.  Rec'd a phone call in the middle of the night years ago.  3 out of 4 units were transfused to the incorrect patient.  Fortunately both pts were O Pos.  We used Typenex numbers.  BB tech switched the 2 patients; could only be resolved at the bedside. 2u transfused in dialysis.  When asked about the "red" numbers I was told that they no longer checked them as they always matched.  I informed them that they gave 2u the day before to the incorrect patient.