What's in a name? Patient registration errors and their threat to transfusion safety

Judicialization of nursing malpractice in perioperative care, and delivery and birth assistance

OBJECTIVES

to analyze the legal outcomes of malpractices in perioperative care, and delivery and birth assistance related to nursing, from the perspective of legal support for malpractice prevention.

METHODS

an exploratory, documentary, qualitative study, based on the cases tried by the Court of Justice of the State of Paraná, available online until April 2018. For the data analysis, we codified the processes and summarized the judicial outcome by the severity of the malpractice. Then, we recommended practices for the prevention of each case we presented.

RESULTS

among the thirteen processes analyzed, eight corresponded to the perioperative period (mainly electrocautery burn), and five to nursing care for delivery and birth. The severity of the cases was high (n=7). The judicial outcome of most cases (n=11) was the conviction of the institution.

CONCLUSIONS

despite the multifactorial nature of the malpractices, the identified ones are preventable since there is a description of good practices.

Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017

BACKGROUND AND OBJECTIVES

The key first step for a safe blood transfusion is patient registration for identification and linking to past medical and transfusion history. In Canada, any deviation from standard operating procedures in transfusion is an error voluntarily reportable to a national database (Transfusion Error Surveillance System [TESS]). We used this database to characterize the subset of registration-related errors impacting transfusion care, including where, when and why the errors occurred, and to identify frequent high-risk errors.

MATERIALS AND METHODS

A retrospective analysis was conducted on transfusion errors reported to TESS by sentinel reporting sites relating to patient registration and patient armbands, between 2008 and 2017. Free-text comments describing the error were coded to further categorize into common error types. The number of specimens received in the transfusion laboratory was used as the denominator for rates to allow for comparison between hospital sites.

RESULTS

Five hundred and fifty-four registration errors were reported from 10 hospitals, for a global error rate of 5·4/10 000 samples (median 5·0 [interquartile range 3·7-7·0]). The potential severity was high in 85·7% of errors (n = 475). The patient experienced a consequence in 10·8% of errors (n = 60), but none resulted in patient harm. Rates varied widely and differed by nature across sites. Errors most commonly occurred in outpatient clinics or procedure units (n = 160, 28·8%) and in emergency departments (n = 130, 23·5%).

CONCLUSION

Registration errors affect transfusion at every step and location in the hospital and are commonly high risk. Further research into common root causes is warranted to identify preventative strategies.