Human errors in manual techniques for ABO/D grouping are associated with potentially lethal outcomes

Feasibility and performance of in-house red blood cell reagents to detect unexpected antibodies in immunized patients in Burkina Faso

In sub-Saharan Africa, antibody detection tests remain inaccessible because of the high cost and limited shelf life of red blood cell (RBC) reagents. This study aimed at investigating the feasibility and performance of locally prepared RBC reagents for antibody detection in Burkina Faso. We conducted an experimental study comparing commercial RBC panels and a local panel prepared from phenotyped blood donors in Ouagadougou, Burkina Faso. Antibody detection testing was performed by the indirect antiglobulin test using a gel card filtration column in a low-ionic-strength solution. Judgment criteria were the concordance rate and the kappa agreement coefficient of results generated by the two panels. A total of 302 blood donors were phenotyped for the major antigens of the RH, KEL, MNS, FY, JK, LE, and P1PK blood group systems. From this pool of donors, we designed an RBC detection panel that was used to screen for unexpected antibodies in 1096 plasma samples from 832 patients with a history of transfusion and 264 recently delivered or pregnant women with no history of blood transfusion. A positive antibody detection test was observed in 8.1 percent of the samples using the local panel versus 6.4 percent with the commercial panels. A total of 23 samples were negative with the commercial panels and positive with the local panel, while the findings were reversed for four samples. The concordance rate was 97.5 percent, and the kappa agreement coefficient was 0.815. Our results suggest that the development of local RBC panels can be an alternative to commercial panels in countries with limited resources. It could also be a cost-effective intervention, mainly for children under 5 years of age, women of childbearing age, and pregnant women, all of whom are most at risk for malaria and sickle cell disease complications. Blood services could develop and implement appropriate strategies to make phenotyped donor pools available for the design of suitable RBC panels.

Six Sigma in blood transfusion services: A dream too big in a third world country?

BACKGROUND AND OBJECTIVES

Transfusion errors can occur anywhere from blood donation to final blood transfusion. They are a source of increased cost and patient mortality. Automated workflows can reduce transcription errors, but resource-poor centres still use semi-automated/manual method for testing including manual labelling of column agglutination cards/testing tubes. Missing out any details on these cards can lead to errors in reporting results, wastage and loss of resources and effort. The aim of this study was to implement Six Sigma DMAIC (Define, Measure, Analyse, Improve and Control) methodology to reduce transcription errors while labelling gel card in immunohaematology lab to zero defect.

MATERIALS AND METHODS

In this prospective study, transcription errors while manually performing 200 tests with 1400 opportunities were analysed. Baseline variables like number of errors, defects per million opportunities and sigma level in our current setup were measured. With the application of DMAIC methodology, root cause analysis for each error using Ishikawa diagram and structured Interviews were done to identify causes. A multipronged approach to deal with errors was done to improve critical areas using brainstorming sessions and developing training sheets for practice. After implementing the changes, baseline variables were reanalysed.

RESULTS

Application of DMAIC resulted in an overall reduction in defects from 34.86% to 0.56% with sigma level improvement from 1.89 to 4.08.

CONCLUSION

Six Sigma methodology can be used in a resource-poor setting even with lack of automation to ensure error-free process flow.

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery

BACKGROUND

The past half century has seen the near eradication of transfusion-associated hazards. Intraoperative cell salvage while widely used still poses significant risks and hazards due to human error. We report on a case in which blood collected from a patient with lung cancer was mistakenly administered to a patient undergoing cardiac surgery who should have received his own collected blood. The initial investigation found that the cause of the patient harm was violations of procedures by hospital personnel. A detailed investigation revealed that not only violations were the cause, but also that the underlying causes included haphazard organizational policies, poor communication, workload and staffing deficiencies, human factors and cultural challenges.

CASE PRESENTATION

On August 14, 2019, a 72-year-old male was admitted to our hospital for angina pectoris and multivessel coronary artery disease. Cardiac surgery was performed using an autologous salvage blood collection system, and there were no major problems other than the prolonged operation time. During the night after the surgery, when the patient's blood pressure dropped, a nurse retrieved a blood bag from the ICU refrigerator that had been collected during the surgery and administered it at the physician's direction, but at this time neither the physician nor the nurse performed the required checking procedures. The blood administered was another patient's blood taken from another surgery the day before; an ABO mismatch transfusion occurred and the patient was diagnosed with DIC. The patient was discharged 65 days later after numerous interventions to support the patient. An accident investigation committee was convened to analyze the root causes and develop countermeasures to prevent a recurrence.

CONCLUSION

This adverse event occurred because the protocol for intraoperative blood salvage management was not clearly defined, and the procedure was different from the standard transfusion practices. We developed a new workflow based on a human factors grounded, systems-wide improvement strategy in which intraoperative blood collection would be administered before the patient leaves the operating room to completely prevent recurrence, instead of simply requiring front-line staff to do a double-check. Implementing strong systems processes can reduce the risk of errors, improve the reliability of the work processes and reduce the likelihood of patient harm occurring in the future.

ABO-Incompatible Transfusion Events Reported in Written Judgments and in the Korean Hemovigilance System

Fatal ABO-incompatible (ABOi) transfusion is one of the most common causes of transfusion-related death, but its reporting has been limited in Korea. We comprehensively reviewed ABOi transfusion events in Korea by analyzing cases reported in literature, Korean hemovigilance system (KOHEVIS) annual reports, and written judgments. Written judgments were assessed using a written judgment management system or a comprehensive legal information system. We found nine cases of ABOi transfusion events in written judgments (from 1953 to 2019), 16 in the KOHEVIS (from 2008 to 2018), and nine in published reports (from 1978 to 2019). One case was found in all three sources. Overall, we found 32 cases of ABOi transfusion events. Four cases died and 23 survived, while the outcomes for five were unavailable. ABOi transfusion errors occurred at the administration (50%, 16/32), sample (13%, 4/32), and testing (9%, 3/32) stages. The causes of errors were unavailable for nine cases (28%, 9/32). We report the status of ABOi transfusions in Korea and expect our results to contribute to the prevention of adverse reactions due to ABOi transfusion.