Quality of transfusion practice beyond the blood transfusion laboratory is essential to prevent ABO-incompatible death

Patient safety challenges in a case study hospital--of relevance for transfusion processes?

The paper reports results from a research project with the objective of studying patient safety, and relates the finding to safety issues within transfusion medicine. The background is an increased focus on undesired events related to diagnosis, medication, and patient treatment in general in the healthcare sector. The study is designed as a case study within a regional Norwegian hospital conducting specialised health care services. The study includes multiple methods such as interviews, document analysis, analysis of error reports, and a questionnaire survey. Results show that the challenges for improved patient safety, based on employees' perceptions, are hospital management support, reporting of accidents/incidents, and collaboration across hospital units. Several of these generic safety challenges are also found to be of relevance for a hospital's transfusion service. Positive patient safety factors are identified as teamwork within hospital units, a non-punitive response to errors, and unit manager's actions promoting safety.

Designing property specifications to improve the safety of the blood transfusion process

Computer scientists use a number of well-established techniques that have the potential to improve the safety of patient care processes. One is the formal definition of a process; the other is the formal definition of the properties of a process. Even highly regulated processes, such as laboratory specimen acquisition and transfusion therapy, use guidelines that may be vague, misunderstood, and hence erratically implemented. Examining processes in a systematic way has led us to appreciate the potential variability in routine health care practice and the impact of this variability on patient safety in the clinical setting. The purpose of this article is to discuss the use of innovative computer science techniques as a means of formally defining and specifying certain desirable goals of common, high-risk, patient care processes. Our focus is on describing the specification of process properties, that is, the high-level goals of a process that ultimately dictate why a process should be performed in a given manner.

Blood transfusions in children: a multi-institutional analysis of practices and complications

BACKGROUND

Blood product transfusions are a valuable health-care resource. Guidelines for transfusion exist, but variability in their application, particularly in children, remains. The risk factors that threaten transfusion safety are well established, but because their occurrence in children is rare, single-institution studies have limited utility in determining the rates of occurrence. An epidemiologic approach that investigates blood transfusions in hospitalized children may help improve our understanding of transfused blood products in this vulnerable population.

STUDY DESIGN AND METHODS

This was a nonconcurrent cohort study of pediatric patients not more than 18 years of age hospitalized from 2001 to 2003 at 35 academic children's hospitals that are members of the Pediatric Health Information System (PHIS).

RESULTS

A total of 51,720 (4.8%) pediatric patients received blood product transfusions during the study period. Red blood cells (n = 44,632) and platelets (n = 14,274) were the two most frequently transfused products. The rate of transfusions was highest among children with neutropenia, agranulocytosis, and sickle cell crisis. Asian and American Indian patients had important differences in the rate of blood transfusions and their complications. Resource use in terms of length of stay and costs were higher in patients who received transfusion. Of those patients who received transfusions, 492 (0.95%) experienced a complication from the administered blood product. This accounted for a rate of complications of 10.7 per 1,000 units transfused.

CONCLUSIONS

The administration of blood products to children is a common practice in academic children's hospitals. Complications associated with these transfused products are rare.

Increasing patient safety and efficiency in transfusion therapy using formal process definitions

The administration of blood products is a common, resource-intensive, and potentially problem-prone area that may place patients at elevated risk in the clinical setting. Much of the emphasis in transfusion safety has been targeted toward quality control measures in laboratory settings where blood products are prepared for administration as well as in automation of certain laboratory processes. In contrast, the process of transfusing blood in the clinical setting (ie, at the point of care) has essentially remained unchanged over the past several decades. Many of the currently available methods for improving the quality and safety of blood transfusions in the clinical setting rely on informal process descriptions, such as flow charts and medical algorithms, to describe medical processes. These informal descriptions, although useful in presenting an overview of standard processes, can be ambiguous or incomplete. For example, they often describe only the standard process and leave out how to handle possible failures or exceptions. One alternative to these informal descriptions is to use formal process definitions, which can serve as the basis for a variety of analyses because these formal definitions offer precision in the representation of all possible ways that a process can be carried out in both standard and exceptional situations. Formal process definitions have not previously been used to describe and improve medical processes. The use of such formal definitions to prospectively identify potential error and improve the transfusion process has not previously been reported. The purpose of this article is to introduce the concept of formally defining processes and to describe how formal definitions of blood transfusion processes can be used to detect and correct transfusion process errors in ways not currently possible using existing quality improvement methods.

Reliability of bedside ABO testing before transfusion

BACKGROUND

Previous studies of bedside transfusion compatibility tests have shown high rates of erroneous transfusion decision, due to defective techniques and poor user performance. An experimental study was conducted to evaluate the error rate obtained with a new ready-to-use device (Vu-Test, Medigis), in comparison with the most popular bedside card used in France (Safety-Test ABO, Diagast Laboratories).

STUDY DESIGN AND METHODS

A stratified random sample of nurses performed, in the clinical departments where they worked, cross-matches on 12 randomly and blindly selected paired donor-recipient blood samples with Safety-Test ABO and Vu-Test. The nurses detected agglutination, interpreted compatibility, decided whether to transfuse, and gave their opinion of the two devices. Three independent experts reviewed photographs of each test result.

RESULTS

Thirty-five trained nurses and 10 student nurses carried out 268 tests with each device. One-hundred ninety tests (70.9%) performed with Safety-Test ABO and 177 tests (66.0%) performed with Vu-Test were entirely error-free (p=0.23). The risk of erroneous detection of agglutination was not different between the devices (p=0.69), but was significantly lower when the nurse had experience in transfusion (p < 0.001). According to the experts, Vu-Test was significantly better than Safety-Test ABO.

CONCLUSION

Although the experts considered Vu-Test to be better than Safety-Test ABO, error rates were high with both devices.

The computer crossmatch: a safe alternative to the serological crossmatch

The crossmatch has evolved from including a wide range of techniques through a test purely to eliminate ABO incompatibility (immediate spin) to computer crossmatching in which no serological testing is carried out and validation ensures the correct ABO/RhD type blood is issued. The crossmatch was always considered to be the most important feature of the compatibility test and in particular the antiglobulin phase; however, there are potential risks associated with serological and computer crossmatching including technical and procedural errors. The use of immediate spin and computer crossmatch change the emphasis for safety of the compatibility test from the crossmatch to the antibody screen. UK guidelines have now been published describing the features necessary for the introduction of computer crossmatching. Computer crossmatching is used by many institutions in various countries. It is considered safe practice and brings benefits to the laboratory and the patient. Compatibility testing is only one element of the blood transfusion procedure; the others are equally as important and include correct patient identification at the time of collection of the blood sample and at the administration of the blood transfusion.