Root cause analysis of non-infectious transfusion complications and the lessons learnt

Investigating the quality of hemovigilance process using the first two steps of Six Sigma model: a cross-sectional study

BACKGROUND AND PURPOSE

Hemovigilance is a set of monitoring methods that covers the blood transfusion chain, from collecting blood and blood products to monitoring the blood recipients. To this end, any error in this process can have serious and irreparable consequences for patients. The present study aimed to investigate the quality of hemovigilance process in Iran, using the first two steps of Six Sigma model.

METHODS

This was a quantitative cross-sectional study that was conducted over 6 months (from August 20, 2021, to February 20, 2022) at Afzalipour Hospital in Iran, using the first two steps of Six Sigma model. The study population comprised of all inpatients who needed blood or blood product transfusion in various departments of Afzalipour Hospital, among whom 477 patients were selected via stratified sampling in three shifts (morning, evening, and night). The datasheet was used to record errors in the three shifts. This research was conducted, using the DMAIC cycle's "define" and "measure" steps.

RESULTS

In the define step, the hemovigilance process at Afzalipour Hospital was divided into two categories of normal process and emergency process. Each of these processes consists of several sub-processes, including "phlebotomy," "requesting blood and blood products from the department," "preparation of application by the blood bank," " sending a request from the blood bank to the blood transfusion center," "transfusing blood and blood products," and "returning the blood and blood products to the blood bank and waste disposal." In the measure step, the quality of hemovigilance process was evaluated based on sub-processes and labels at morning, evening and night shifts. The sub-process of sending a request from the blood bank to the blood transfusion center had the highest error rate with a sigma level of 1.5. Also, the evening and night shifts had a sigma level of 1.875, and the clinical and registration labels had a sigma level of 1.875. The overall sigma level of hemovigilance process was calculated to be 2.

CONCLUSION

The results of this study showed that the quality of hemovigilance process at Afzalipour Hospital was poor. By employing the first two steps of Six Sigma method, we identified the existing errors in the hemovigilance process of Afzalipour hospital in order to assist hospital managers to take the necessary measures to improve this process.

Non-severe allergic transfusion reaction: A hidden cause of wastage of blood product and laboratory resources

BACKGROUND AND OBJECTIVES

Blood transfusions are often needlessly aborted following a non-severe allergic reaction despite responding well to medication resulting into partial transfusion of the implicated blood product. This results in the wastage of untransfused blood component and resources spent on unnecessary laboratory work-up of these reactions.

MATERIALS AND METHODS

We aimed to review the amount of blood product and laboratory resource wastage associated with non-severe allergic transfusion reaction (ATR) in a tertiary care hospital.

RESULTS

A total of 174,632 blood products were released and transfused during the study period (2019-2021). There were 336 adverse transfusion reactions with an estimated rate of 1.9 per 1000 blood products administered. Of 336, 145 (43%) were ATR, of which 141 (97%) were non-severe and 4 (3%) were severe. The most commonly associated symptom was found to be urticaria in 31 (22%). All non-severe ATR completely resolved with medication. Seventy-nine percent of the transfusions associated with non-severe ATRs were aborted, of which 37% were followed by additional transfusions. The estimated loss of blood product volume and the cost of non-severe ATR (including transfusion reaction work-up, discarded blood product and additional transfusion) was 11,185 ml (11 L) and Pakistani rupees 1,831,546 ($11,592.06 or €8598.78), respectively.

CONCLUSION

Non-severe ATR was found to be associated with a significant proportion of laboratory resource wastage and that of blood product in our institution. Revision of institutional guidelines for management and lab work-up of transfusion reactions would be helpful in alleviating this unnecessary loss in a resource-constraint transfusion-setting.

A structured approach to analyse logistics risks in the blood transfusion process

Blood transfusion is a critical health care process due to the nature of the products handled and the complexity driven by the strong interdependence among the sub-processes involved. Most of the errors causing adverse events originate during the blood logistics activities. Several literature contributions apply risk management to the transfusion process but often in a fragmented and reactive way. Moreover, few of them focus on logistics risks and assess the effectiveness of risk responses through operational key performance indicators (KPIs). The present paper applies a comprehensive and structured approach to proactively identify and analyse logistics risks as well as define responses to improve blood bag traceability, focusing on hospital wards. The implementation of such actions is monitored by specific KPIs whose measurement enables an improved communication flow among actors allowing to uncover residual risks. Future research will extend the application to further blood transfusion settings and supply chain echelons. The outcomes of this work might assist practitioners in improving policy making about blood supply chains. As a matter of fact, they allow a better understanding of the associated material and informational flows and the related risks, which supports setting effective strategies to either prevent adverse events or mitigate their effects.

Transfusion-Associated Circulatory Overload: A Clinical Perspective

For 30 years, transfusion-associated circulatory overload (TACO) has been recognized as a serious transfusion complication. Currently, TACO is the leading cause of transfusion-related morbidity and mortality worldwide which occurs in 1% to 12% of at-risk populations. Despite an incomplete understanding of the underlying pathophysiology, TACO is defined as a collection of signs and symptoms of acute pulmonary edema due to circulatory overload occurring within 6 to 12 hours of transfusion. In the past decade, large observational cohort studies resulted in better insight into the associated transfusion risk factors leading to the development of TACO. In this clinical review, we critically analyze the pathogenesis of TACO, associated risk factors, clinical presentation, diagnostic modalities, and treatment options to guide clinicians with early detection of this syndrome and intervention to improve clinical outcomes. Future research should focus on better understanding of the pathogenesis to help advance the field of volume kinetics and endothelial barrier function.

Improving platelet transfusion safety: biomedical and technical considerations

Platelet concentrates account for near 10% of all labile blood components but are responsible for more than 25% of the reported adverse events. Besides factors related to patients themselves, who may be particularly at risk of side effects because of their underlying illness, there are aspects of platelet collection and storage that predispose to adverse events. Platelets for transfusion are strongly activated by collection through disposal equipment, which can stress the cells, and by preservation at 22 °C with rotation or rocking, which likewise leads to platelet activation, perhaps more so than storage at 4 °C. Lastly, platelets constitutively possess a very large number of bioactive components that may elicit pro-inflammatory reactions when infused into a patient. This review aims to describe approaches that may be crucial to minimising side effects while optimising safety and quality. We suggest that platelet transfusion is complex, in part because of the complexity of the "material" itself: platelets are highly versatile cells and the transfusion process adds a myriad of variables that present many challenges for preserving basal platelet function and preventing dysfunctional activation of the platelets. The review also presents information showing--after years of exhaustive haemovigilance--that whole blood buffy coat pooled platelet components are extremely safe compared to the gold standard (i.e. apheresis platelet components), both in terms of acquired infections and of immunological/inflammatory hazards.

Active Hemovigilance Significantly Improves Reporting of Acute Non-infectious Adverse Reactions to Blood Transfusion

One of the key purposes of a hemovigilance program is to improve reporting of transfusion related adverse events and subsequent data-driven improvement in blood transfusion (BT) practices. We conducted a study over 3 years to assess the impact of healthcare worker training and an active feedback programme on reporting of adverse reactions to BTs. All hospitalized patients who required a BT were included in the study. Healthcare workers involved in BT to patients were sensitized and trained in adverse reaction reporting by conducting training sessions and meetings. All the transfused patients were 'actively' monitored for any acute adverse reaction by using a uniquely coded blood issue form. A total of 18,914 blood components transfused to 5785 different patients resulted in 61 adverse reaction episodes. This incidence of 0.32 % in our study was found to be significantly higher (p < 0.005) than that reported from the same region in the past. Red blood cell units were the most frequently transfused component and thus most commonly involved in an adverse reaction (42.6 %), however apheresis platelets had the highest chance of reaction per unit transfused (0.66 %). There was no mortality associated with the BT during the study period. An active surveillance program significantly improves reporting and management of adverse reactions to BTs.