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Patient Verification Key to Preventing Transfusion Reactions

March 12, 2008
Written by: , Filed in: Practice Management
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The most common reason for hemolytic transfusion reactions due to
administration of ABO incompatible blood appears to be in the failure to
verify that the correct patient is receiving the blood.

Part of the National Quality Forum’s list of ‘never events’ includes
preventable medical errors that are categorized under the heading of care
management events. One of these items is patient death or serious disability
associated with hemolytic transfusion reaction due to administration of ABO
incompatible blood or blood product. An enormous amount of time and energy has
been spent to create a safe system for blood transfusion.

An enormous amount of testing must happen in the lab to find out what kind of
blood the patient has, whether they have antigens, and whether there is going
to be difficulty transfusing a patient. We need to be acutely aware of the
complicated nature of this system. Most people deal with only one piece of the
system and do not look at the overall system.

We recently investigated a situation in which a patient received the wrong
blood, which led to the patient’s death. In going backward from the point of
transfusion, everything in the transfusion system was predicated on the person
who encountered the patient in the previous step in the process doing
everything the right way.

What the investigation revealed was that an error had been made in the first
step–at the step of patient identification. Therefore, talking to patients
and following the steps required for transfusion are both keys to preventing
transfusion reactions.

Other transfusion-related events with which we have become familiar all
involved the same thing–“I thought I had the right person.” The error does
not usually involve the blood that comes from the blood bank, or the double-
checking process with which people are so familiar. Instead, the error usually
involves the simple points of: “Do I have the right person in front of me?”
and “Is his/her band giving me the same information that the patient is giving
me?”

You cannot assume anything, and you cannot assume that someone else has done
what they are supposed to have done, especially if you are serving as the
double-check or the redundancy in the system. You must ensure that everything
has been done and not just rely on someone saying, “Yeah I did the math here.
I’ve done that.” You must double-check things from step one.

Reference:
Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events:
Hemolytic Transfusion Reactions Due to Administration of Incompatible
Blood.

The most common reason for hemolytic transfusion reactions due to administration of ABO incompatible blood appears to be in the failure to verify that the correct patient is receiving the blood. Part of the National Quality Forum’s list of 'never events' includes preventable medical errors that are categorized under the heading of care management events. One of these items is patient death or serious disability associated with hemolytic transfusion reaction due to administration of ABO incompatible blood or blood product. An enormous amount of time and energy has been spent to create a safe system for blood transfusion. An enormous amount of testing must happen in the lab to find out what kind of blood the patient has, whether they have antigens, and whether there is going to be difficulty transfusing a patient. We need to be acutely aware of the complicated nature of this system. Most people deal with only one piece of the system and do not look at the overall system. We recently investigated a situation in which a patient received the wrong blood, which led to the patient's death. In going backward from the point of transfusion, everything in the transfusion system was predicated on the person who encountered the patient in the previous step in the process doing everything the right way. What the investigation revealed was that an error had been made in the first step--at the step of patient identification. Therefore, talking to patients and following the steps required for transfusion are both keys to preventing transfusion reactions. Other transfusion-related events with which we have become familiar all involved the same thing--"I thought I had the right person." The error does not usually involve the blood that comes from the blood bank, or the double- checking process with which people are so familiar. Instead, the error usually involves the simple points of: "Do I have the right person in front of me?" and "Is his/her band giving me the same information that the patient is giving me?" You cannot assume anything, and you cannot assume that someone else has done what they are supposed to have done, especially if you are serving as the double-check or the redundancy in the system. You must ensure that everything has been done and not just rely on someone saying, "Yeah I did the math here. I've done that." You must double-check things from step one. Reference: Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events: Hemolytic Transfusion Reactions Due to Administration of Incompatible Blood. [text_ad]
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