The BCSH guideline on addressograph labels: experience at a cardiothoracic unit and findings of a telephone survey

Quantitative assessment of prevalence of pre-analytical variables and their effect on coagulation assay. Can intervention improve patient safety?

BACKGROUND

Very few Indian studies exist on evaluation of pre-analytical variables affecting "Prothrombin Time" the commonest coagulation assay performed. The study was performed in an Indian tertiary care setting with an aim to assess quantitatively the prevalence of pre-analytical variables and their effects on the results (patient safety), for Prothrombin time test. The study also evaluated their effects on the result and whether intervention, did correct the results.

METHODS

The firstly evaluated the prevalence for various pre-analytical variables detected in samples sent for Prothrombin Time testing. These samples with the detected variables wherever possible were tested and result noted. The samples from the same patients were repeated and retested ensuring that no pre-analytical variable is present. The results were again noted to check for difference the intervention produced.

RESULTS

The study evaluated 9989 samples received for PT/INR over a period of 18 months. The prevalence of different pre-analytical variables was found to be 862 (8.63%). The proportion of various pre-analytical variables detected were haemolysed samples 515 (5.16%), over filled vacutainers 62 (0.62%), under filled vacutainers 39 (0.39%), low values 205 (2.05%), clotted samples 11 (0.11%), wrong labeling 4 (0.04%), wrong vacutainer use 2 (0.02%), chylous samples 7 (0.07%) and samples with more than one variable 17 (0.17%). The comparison of percentage of samples showing errors were noted for the first variables since they could be tested with and without the variable in place. The reduction in error percentage was 91.5%, 69.2%, 81.5% and 95.4% post intervention for haemolysed, overfilled, under filled and samples collected with excess pressure at phlebotomy respectively.

CONCLUSION

Correcting the variables did reduce the error percentage to a great extent in these four variables and hence the variables are found to affect "Prothrombin Time" testing and can hamper patient safety.

Report on errors in pretransfusion testing from a tertiary care center: A step toward transfusion safety

INTRODUCTION

Errors in the process of pretransfusion testing for blood transfusion can occur at any stage from collection of the sample to administration of the blood component. The present study was conducted to analyze the errors that threaten patients' transfusion safety and actual harm/serious adverse events that occurred to the patients due to these errors.

MATERIALS AND METHODS

The prospective study was conducted in the Department Of Transfusion Medicine, Shri Maharaja Gulab Singh Hospital, Government Medical College, Jammu, India from January 2014 to December 2014 for a period of 1 year. Errors were defined as any deviation from established policies and standard operating procedures. A near-miss event was defined as those errors, which did not reach the patient. Location and time of occurrence of the events/errors were also noted.

RESULTS

A total of 32,672 requisitions for the transfusion of blood and blood components were received for typing and cross-matching. Out of these, 26,683 products were issued to the various clinical departments. A total of 2,229 errors were detected over a period of 1 year. Near-miss events constituted 53% of the errors and actual harmful events due to errors occurred in 0.26% of the patients. Sample labeling errors were 2.4%, inappropriate request for blood components 2%, and information on requisition forms not matching with that on the sample 1.5% of all the requisitions received were the most frequent errors in clinical services. In transfusion services, the most common event was accepting sample in error with the frequency of 0.5% of all requisitions. ABO incompatible hemolytic reactions were the most frequent harmful event with the frequency of 2.2/10,000 transfusions.

CONCLUSION

Sample labeling, inappropriate request, and sample received in error were the most frequent high-risk errors.

Interventions to reduce wrong blood in tube errors in transfusion: a systematic review

This systematic review addresses the issue of wrong blood in tube (WBIT). The objective was to identify interventions that have been implemented and the effectiveness of these interventions to reduce WBIT incidence in red blood cell transfusion. Eligible articles were identified through a comprehensive search of The Cochrane Library, MEDLINE, EMBASE, Cinahl, BNID, and the Transfusion Evidence Library to April 2013. Initial search criteria were wide including primary intervention or observational studies, case reports, expert opinion, and guidelines. There was no restriction by study type, language, or status. Publications before 1995, reviews or reports of a secondary nature, studies of sampling errors outwith transfusion, and articles involving animals were excluded. The primary outcome was a reduction in errors. Study characteristics, outcomes measured, and methodological quality were extracted by 2 authors independently. The principal method of analysis was descriptive. A total of 12,703 references were initially identified. Preliminary secondary screening by 2 reviewers reduced articles for detailed screening to 128 articles. Eleven articles were eventually identified as eligible, resulting in 9 independent studies being included in the review. The overall finding was that all the identified interventions reduced WBIT incidence. Five studies measured the effect of a single intervention, for example, changes to blood sample labeling, weekly feedback, handwritten transfusion requests, and an electronic transfusion system. Four studies reported multiple interventions including education, second check of ID at sampling, and confirmatory sampling. It was not clear which intervention was the most effective. Sustainability of the effectiveness of interventions was also unclear. Targeted interventions, either single or multiple, can lead to a reduction in WBIT; but the sustainability of effectiveness is uncertain. Data on the pre- and postimplementation of interventions need to be collected in future trials to demonstrate effectiveness, and comparative studies are needed of different interventions.

Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test request management and test tube labelling

: Most errors in laboratory medicine occur in the preanalytical phase and are the result of human mistakes. This study investigated information search procedures, test request management and test tube labelling in primary healthcare compared to the same procedures amongst clinical laboratory staff.

: A questionnaire was completed by 317 venous blood sampling staff in 70 primary healthcare centres and in two clinical laboratories (response rate = 94%).

: Correct procedures were not always followed. Only 60% of the primary healthcare staff reported that they always sought information in the updated, online laboratory manual. Only 12% reported that they always labelled the test tubes prior to drawing blood samples. No major differences between primary healthcare centres and clinical laboratories were found, except for test tube labelling, whereby the laboratory staff reported better practices. Re-education and access to documented routines were not clearly associated with better practices.

: The preanalytical procedure in the surveyed primary healthcare centres was associated with a risk of errors which could affect patient safety. To improve patient safety in laboratory testing, all healthcare providers should survey their preanalytical procedures and improve the total testing process with a systems perspective.

Clin Chem Lab Med 2009;47:195–201.

Tubes for pretransfusion testing should be collected by blood bank staff and hand labelled until the implementation of new technology for improved sample labelling. Results of a prospective study

BACKGROUND AND OBJECTIVES

The greatest risk in transfusion medicine is actually human error, resulting in the use of the incorrect blood component. The aim of our study was to identify and evaluate the risk factors involved in the collection and labelling of pretransfusion blood samples.

MATERIAL AND METHODS

We prospectively evaluated 6446 samples submitted to the blood bank for pretransfusion testing. Inappropriate samples were classified as 'mislabelled' or 'miscollected'. After 4 months of study, an educational approach was taken.

RESULTS

The frequency of inappropriately labelled samples was 6.45%. Such samples were associated with the use of addressograph labels (vs. hand-written labels) [23.4% vs. 1.4%, P < 0.0001], collection by clinical staff (vs. blood bank staff) [8.8% vs. 2.1%, P = 0.001] and emergency situations (vs. routine sampling) [10.1% vs. 6.1%, P = 0.005]. Following educational intervention, the percentage of inappropriately labelled samples decreased from 7.3% (pre-educational) to 5.8% (post-educational), P = 0.005.

CONCLUSION

Ongoing monitoring and analysis of labelling and collection should be mandatory in order to improve the safety of transfusion.

ABO incompatible transfusions--experience from the UK Serious Hazards of Transfusion (SHOT) scheme Transfusions ABO incompatible

The Serious Hazards of Transfusion (SHOT) scheme has now accumulated 8 years' data. The most frequently occurring adverse event, accounting for 1832/2628 (70%) of incidents reported, is 'incorrect blood component transfused' (IBCT) in which the patient receives a blood component that did not meet the correct specification or that was intended for another patient. Errors can occur at all stages of the transfusion chain and, in about half of cases, multiple system failures can be identified. Analysis of 130 ABO incompatible transfusions reported between 1999 and 2003 identified 221 separate errors, 68% of which took place in clinical areas and 29% in hospital laboratories. The commonest single error is failure to check at the bedside that the right blood is being given to the right patient. Certain patients, e.g. neonates, those transfused at night and in critical care situations, appear to be particularly vulnerable. It is encouraging that, against a background of ever increasing numbers year-on-year of reports of IBCT, the incidence of ABO incompatible transfusions already shows a downward trend, suggesting the emergence of a safety culture.

Reducing adverse events in blood transfusion

Against a background of ever increasing expenditure on blood safety, less attention has been paid to improving the safety of the transfusion chain within hospitals. Based on reports to the Serious Hazards of Transfusion (SHOT scheme) between 1996 and 2003, the risk of an error occurring during transfusion of a blood component is estimated at 1:16 500, an ABO incompatible transfusion at 1:100 000 and the risk of death as a result of an 'incorrect blood component transfused' (IBCT) is around 1:1 500 000. There are opportunities for error at a number of critical points in the transfusion chain, starting with the decision to transfuse, prescription and request, patient sampling, pretransfusion testing and finally the collection of the component from the blood refrigerator and administration to the patient, consistently the commonest error in successive SHOT reports. Successive 'Better Blood Transfusion' initiatives and the 2003 Annual Report of the Chief Medical Officer for England have drawn welcome attention to the importance of safe and appropriate transfusion and the National Patient Safety Agency has now set a target of reducing the number of ABO incompatible transfusions by 50% over 3-5 years.

Errors in transfusion medicine

In the past two decades, health services in the developed world have directed much resource toward improving the safety of the blood supply. Blood is collected, tested, and processed within a carefully controlled environment, and quality is assured by rigorous donor selection procedures and increasingly sensitive and sophisticated testing for transfusion-transmitted pathogens. Additional safety strategies implemented by some blood services include leukocyte reduction, bacterial screening, and pathogen inactivation. Thus, the transfusion chain from the donor to the point of issue from the blood center is highly regulated and secure, and transfusion-transmitted infection is an increasingly rare event.

Experience with the medical event reporting system for transfusion medicine (MERS-TM) at three hospitals

BACKGROUND

The MERS-TM assists hospital transfusion services to identify, analyze, and correct system events relating to the delivery of blood to patients.

METHODS

The MERS-TM system was used from February of 1999 to December 2002. All reported near-miss and actual events were recorded and analyzed.

RESULTS

During these 47 months, 4670 events were reported by the transfusion service. Of these events, 94% were classified as a near-miss event and 93% were detected before the blood product was administered. No ABO-incompatible transfusions were detected despite transfusion of 50,137 units of red blood cells. High severity events with the potential for patient harm accounted for 241 (5%) of the 4670 events. Nursing related events accounted for 188 (78%) of the high severity events. In one out of 4430 (0.023%) samples tested, a high severity sample-testing event was detected. In one out of 1550 (0.06%) samples collected, a high severity sample-collection event was detected.

CONCLUSION

An event reporting system is essential if one is to determine where and how often events are occurring within the transfusion process.

Reporting of near-miss events for transfusion medicine: improving transfusion safety

BACKGROUND

Half of the reported serious adverse events from transfusion are a consequence of medical error. A no-fault medical-event reporting system for transfusion medicine (MERS-TM) was developed to capture and analyze both near-miss and actual transfusion-related errors.

STUDY DESIGN AND METHODS

A prospective audit of transfusion-related errors was performed to determine the ability of MERS-TM to identify the frequency and patterns of errors.

RESULTS

Events and near-miss events (total, 819) were recorded for a period of 19 months (median, 51/month). No serious adverse patient outcome occurred, despite these events, with the transfusion of 17,465 units of RBCs. Sixty-one events (7.4%) were potentially life-threatening or could have led to permanent injury (severity Level 1). Of most concern were 3 samples collected from the wrong patient, 13 mislabeled samples, and 22 requests for blood for the wrong patient. Near-miss events were five times more frequent than actual transfusion errors, and 68 percent of errors were detected before blood was issued. Sixty-one percent of events originated from patient areas, 35 percent from the blood bank, and 4 percent from the blood supplier or other hospitals. Repeat collection was required for 1 of every 94 samples, and 1 in 346 requests for blood components was incorrect. Education of nurses and alterations to blood bank forms were not by themselves effective in reducing severe errors. An artifactual 50-percent reduction in the number of errors reported was noted during a 6-month period when two chief members of the event-reporting team were on temporary leave.

CONCLUSION

The MERS-TM allowed the recognition and analysis of errors, determination of patterns of errors, and monitoring for changes in frequency after corrective action was implemented. Although no permanent injury resulted from the 819 events, innovative mechanisms must be designed to prevent these errors, instead of relying on faulty informal checks to capture errors after they occur.