Treating a sick process

How to improve issuing, transfusion and follow-up of blood components in Southern and Eastern Mediterranean countries? A benchmark assessment

To determine the existence of guidelines regarding the appropriate clinical use of blood and blood components, transfusion requests, and blood issuing/reception documents and procedures. The different bedside transfusion organizations/processes and hemovigilance are also analyzed. The ultimate objective is to identify safe potential options in order to improve blood safety at the lowest cost. Data emanating from eight Arabic eastern/southern Mediterranean countries who responded to five surveys were collected and tabulated. National recommendations for the clinical use of blood components especially for hemoglobinopathies are lacking in some countries. In matter of good practices in the prescription, issuing and reception of BCs, efforts were made either on national or local basis. Procedures regarding patient information and ethical issues are still lacking. Almost all Mediterranean countries apply two blood testing procedures on each patient sample. Only Morocco, Tunisia and Algeria perform bed side blood group testing; Egypt and Lebanon perform antibody screen and antiglobulin cross matching universally. Automation for blood testing is insufficiently implemented in almost all countries and electronic release is almost absent. National hemovigilance policy is implemented in Tunisia, Morocco, and Lebanon but the reporting system remains inoperative. Insufficient resources severely hinders the implementation of expensive procedures and programs; however, the present work identifies safe procedures that might save resources to improve other parts in the transfusion process (e.g. electronic release to improve safety in issuing). Moreover, setting up regulations regarding ethics in transfusing recipients along with local transfusion committees are crucially needed to implement hemovigilance in transfusion practice.

Assessment of Knowledge and Practice of Blood Transfusion Among Nurses in a Tertiary Care Hospital in India

The purpose of this study was to assess the knowledge and awareness of blood transfusion practices among nurses working in a tertiary care hospital. The objective was to make use of the results to decide the necessity of targeted teaching using lectures and simulated ward scenes. This was a cross sectional study in which a questionnaire comprising of 25 single best-response type multiple choice questions related to blood products and blood transfusion was distributed to nurses who were selected randomly. Questions were both knowledge and practice based. Five hundred and forty-six nurses consented and were assessed. The data was collected, entered and statistically assessed. The number of 'Correct', 'Incorrect' and 'Don't Know' answers were noted. Each correct answer was awarded 1 point, whereas a wrong answer and a 'Don't Know' answer received no points. The individual scores were noted and then multiplied by 4 to get a percentage value. Nurses with 1-5 years of experience scored statistically better than nurses with < 1 year and > 5 years of experience. Nurses working in the haematology-oncology ward scored the most number of correct responses, followed by nurses working in ICU. Only 9.9% of nurses answered > 80% questions correctly. Nurses who had 1-5 years of experience scored better. All nurses were trained in blood transfusion at induction. Though there were occasional non-compulsory lectures as ongoing programs, they had no specific impact on knowledge and awareness. The authors suggest that targeted and regular simulated training is essential at all levels of nursing experience.

After Hour Blood Transfusions: A Transfusion Service Perspective

Optimal functioning of blood transfusion service during after hours with limited resources are highly challenging. Best transfusion practice guidelines recommends to avoid non-urgent transfusions during out-of-core hours for the concern of patient's safety. This study aimed to evaluate the after hour packed red cell transfusion practice and to identify the proportion of avoidable transfusions in our center. The transfusion requests received, cross-matched and issued between 8 p.m. and 8 a.m. from September 2015 to August 2016 were analysed and categorized into 3E's based on the clinical need as Group I-evident need, Group 2-empirical need and Group 3-elective need. The proportion of avoidable transfusion in each group was noted based on BCSH guidelines on red cell transfusion including the patient's clinical, laboratory parameters and transfusion details. The proportion of PRBC requests received, crossmatched and issued between 8 p.m. and 8 a.m. were 24.45%, 23.84% and 27.15% respectively. The rationale for PRBC transfusion documented for evident, empirical and elective need were 56.95%, 29.34% and 13.71% respectively. Out of which, 19.21% [876/4559] was identified as avoidable transfusions providing no immediate clinical benefit to patients. This study highlights the proportion of avoidable transfusion during after hours in our center and emphasizes the need for transfusion guidelines that recommends to restrict after hour transfusions to those patients with active bleeding or urgent clinical need in order to prevent transfusion related adverse events and improve patient safety.

Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety

The Serious Hazards of Transfusion (SHOT) UK confidential haemovigilance reporting scheme began in 1996. Over the 16 years of reporting, the evidence gathered has prompted changes in transfusion practice from the selection and management of donors to changes in hospital practice, particularly better education and training. However, half or more reports relate to errors in the transfusion process despite the introduction of several measures to improve practice. Transfusion in the UK is very safe: 2·9 million components were issued in 2012, and very few deaths are related to transfusion. The risk of death from transfusion as estimated from SHOT data in 2012 is 1 in 322 580 components issued and for major morbidity, 1 in 21 413 components issued; the risk of transfusion-transmitted infection is much lower. Acute transfusion reactions and transfusion-associated circulatory overload carry the highest risk for morbidity and death. The high rate of participation in SHOT by National Health Service organizations, 99·5%, is encouraging. Despite the very useful information gained about transfusion reactions, the main risks remain human factors. The recommendations on reduction of errors through a ‘back to basics’ approach from the first annual SHOT report remain absolutely relevant today.

Serious hazards of transfusion: a decade of hemovigilance in the UK

The Serious Hazards of Transfusion (SHOT) scheme is a UK-wide, independent, professionally led hemovigilance system focused on learning from adverse events. SHOT was established in 1996 as a confidential reporting system for significant transfusion-related events, building an evidence base to support blood safety policy decisions, clinical guidelines, clinician education, and improvements in transfusion practice. Recommendations are formulated by an independent steering group drawn from medical royal colleges and professional bodies. Ten years after its inception, SHOT has analyzed 2630 transfusion safety events, published 8 annual reports with recommendations, and presented data nationally and internationally. These recommendations have underpinned key initiatives, in particular the UK Department of Health "Better Blood Transfusion" strategy. SHOT has encouraged open reporting of adverse events and "near-misses" in a supportive, learning culture, vigilance in hospital transfusion practice, and evaluation of information technology to support this process. The importance of education and training has been emphasized. Detailed analysis of events has identified weaknesses in the transfusion chain. A collaborative initiative between SHOT, the Chief Medical Officer for England's National Blood Transfusion Committee, and the National Patient Safety Agency aims to reduce ABO-incompatible transfusions by improving bedside practice. Cumulative SHOT data have documented the decline in transfusion-related graft vs host disease after implementation of leucodepletion and have highlighted transfusion-related acute lung injury and bacterial contamination of platelets as important causes of death and morbidity. The UK blood services have developed strategies to reduce these risks. Future SHOT data will evaluate the success of these and other blood safety improvements.

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.

Evolution of quality management: integration of quality assurance functions into operations, or "quality is everyone's responsibility"

The management of quality in the Division of Transfusion Medicine at our institution has undergone a lengthy, sometimes painful but always progressive evolution over nearly four decades. Initially, it consisted of one laboratory technologist who was assigned the task of performing certain basic QC checks on a predetermined list of laboratory, collection, and processing steps. This technologist reported directly to the medical director. The tasks gradually grew in volume and complexity so that a four-person quality unit was established, administratively quite separate from the operations and accountable only to the Medical Director. The next stage in the evolutionary process was more revolutionary in scope because it involved a comprehensive cultural shift toward the concept of "quality is everyone's responsibility." The evolutionary process in our institution to date and the planning and organization involved in the direction and management of the evolution itself are described.

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 release of unsuitable units through misinterpretation of laboratory results transmitted by facsimile

BACKGROUND

Preventable errors in transfusion medicine that have a significant risk of adverse outcome include the erroneous administration of blood of the wrong type or blood with unsuitable laboratory test results. Mandatory reports of errors by facilities providing blood services in New York State offer the opportunity for review and analysis of common factors. The state also collects statistics on the collection, laboratory testing, distribution, and disposition of blood in these facilities.

CASE REPORTS

Three serious errors in transfusion medicine occurred within 3 months as a result of the misinterpretation of laboratory test results transmitted by facsimile. Two unsuitable units of blood were erroneously released, and a unit mislabeled as to the ABO group was incorporated into the hospital inventory. One of the unsuitable units was repeatedly reactive for HIV (although negative on confirmatory testing), and the other was confirmed positive for HCV.

CONCLUSIONS

The vast majority of blood collected in New York State is tested by reference laboratories. Results are often transmitted by facsimile. Facsimile results may be misinterpreted because of distortion during transmission, misreading, or failure to note a separate report of pending results. Such misinterpretation results in an increased risk of adverse outcome for transfusion recipients. Laboratory results to be transmitted by facsimile could readily-and should-be clarified.

Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports

OBJECTIVE

To receive and collate reports of death or major complications of transfusion of blood or components.

DESIGN

Haematologists were invited confidentially to report deaths and major complications after blood transfusion during October 1996 to September 1998.

SETTING

Hospitals in United Kingdom and Ireland.

SUBJECTS

Patients who died or experienced serious complications, as defined below, associated with transfusion of red cells, platelets, fresh frozen plasma, or cryoprecipitate.

MAIN OUTCOME MEASURES

Death, "wrong" blood transfused to patient, acute and delayed transfusion reactions, transfusion related acute lung injury, transfusion associated graft versus host disease, post-transfusion purpura, and infection transmitted by transfusion. Circumstances relating to these cases and relative frequency of complications.

RESULTS

Over 24 months, 366 cases were reported, of which 191 (52%) were "wrong blood to patient" episodes. Analysis of these revealed multiple errors of identification, often beginning when blood was collected from the blood bank. There were 22 deaths from all causes, including three from ABO incompatibility. There were 12 infections: four bacterial (one fatal), seven viral, and one fatal case of malaria. During the second 12 months, 164/424 hospitals (39%) submitted a "nil to report" return.

CONCLUSIONS

Transfusion is now extremely safe, but vigilance is needed to ensure correct identification of blood and patient. Staff education should include awareness of ABO incompatibility and bacterial contamination as causes of life threatening reactions to blood.