Adding Automation and Independent Dual Verification to Reduce Wrong Blood in Tube (WBIT) Events

OBJECTIVES

Transfusions remain a complicated procedure involving many disciplines performing various steps. Pretransfusion specimen identification errors remain a concern. Over the past two decades, system changes have been made and minimal improvements in the error rates have been seen. Wrong blood in tube (WBIT) events may lead to mistransfusions of components with life-threatening complications.

METHODS

A continuous quality improvement effort involving the introduction of electronic patient identification at the point of pretransfusion specimen collection (an automated system improvement), manual independent dual verification, and periodic education (human process system improvements) were implemented.

RESULTS

Both automated and human system process improvements resulted in greater than 10-fold reduction in WBIT events and a 47% reduction in mislabeled specimens.

CONCLUSIONS

Diligent improvement and implementation of combination automated system processes and human protocols with continuous monitoring led to great reductions in WBIT error rates and labeling discrepancies, leading to an increase in system safety. These combinations of improvement can lead to more decreased error rates if applied to other critical process steps in the transfusion process.

Evaluation of A plasma for incompatible patients

BACKGROUND

Plasma transfusion is a critical treatment in managing bleeding patients. In an effort to make plasma immediately available in spite of the limited amount of AB plasma, providers have begun using A plasma in life-threatening emergencies. As this practice becomes widely adopted it is important to evaluate safety. Hemolytic transfusions reactions are underreported, and hemolysis may be subclinical.

STUDY DESIGN AND METHODS

A retrospective study was performed at the University of Florida/Shands Hospital of B and AB patients who received 1 unit or more of A plasma. Patient charts were reviewed and data collected included age; sex; mortality; intensive care unit (ICU) length of stay; and laboratory tests used in identifying hemolysis including direct antiglobulin test, lactate dehydrogenase, haptoglobin, indirect bilirubin, aspartate aminotransferase, urinalysis, hemoglobin, and hematocrit. The primary end points of the study were immune mediated hemolysis, mortality, and length of ICU stay.

RESULTS

Ninety-three patients were identified as eligible for the study. One patient suffered a delayed hemolytic transfusion reaction determined to be due to an anti-Jk^a . No evidence of hemolysis due to ABO-incompatible plasma transfusion was identified. The volume of A plasma transfused was found to be weakly related to mortality and ICU stay.

CONCLUSION

No evidence of ABO immune-mediated hemolysis was observed in the patient population. The results of the study support the safety of A plasma transfusion in B and AB patients. We hypothesize the relationship observed between A plasma volume and mortality/ICU stay may be from collinearity with disease severity.