SCENARIO- Hypothetical · The facility had three safety events involving a patient receiving blood transfusions of the wrong blood type. All three patients died. Two (2) patients received their transfusions on a medicine unit and the other patient received his transfusion on a surgical unit. After a root cause analysis, it was found that transfusion orders for each patient were meant for other patients. Additionally, it was found that in two of the cases there were blood specimen labeling errors.Transfusions on a Medicine Essay • In the six (6) months before the deaths of these three patients, the facility had received ten (10) patient safety event reports (JPSR) related to blood labeling errors, but all were caught before a patient was harmed. When staff were interviewed about the event, many reported that communication between clinical staff has always been an issue. Several of the physicians interviewed stated that it is not uncommon for the Laboratory to make errors because nothin

SCENARIO- Hypothetical · The facility had three safety events involving a patient receiving blood transfusions of the wrong blood type. All three patients died. Two (2) patients received their transfusions on a medicine unit and the other patient received his transfusion on a surgical unit. After a root cause analysis, it was found that transfusion orders for each patient were meant for other patients. Additionally, it was found that in two of the cases there were blood specimen labeling errors.Transfusions on a Medicine Essay • In the six (6) months before the deaths of these three patients, the facility had received ten (10) patient safety event reports (JPSR) related to blood labeling errors, but all were caught before a patient was harmed. When staff were interviewed about the event, many reported that communication between clinical staff has always been an issue. Several of the physicians interviewed stated that it is not uncommon for the Laboratory to make errors because nothin

The common fear is that patients get infected while receiving the blood components. It occurs very rare. SHOT acknowledges “that only 1.4 % infected out of 4,334 adverse events between 1996 and 2007”. The greatest risk lies in human error, administering blood to wrong patients or not intended to someone else, accounts to 62.7% of reported cases (SHOT, 2008)

Patient Identification:
While ensuring blood is administered to the right patient, scrupulous enquiry into patient details is mandatory. Identifying patients is vital and must be confirmed when pre-transfusion is taken, collecting the specimen from storage areas and when blood is injected.Transfusions on a Medicine Essay

Checking the blood bag:
Bacteria infected transfusions are major cause of deaths. The staff should remain vigilant and check for the contaminated blood components of red cells and platelet units (SHOT 2008). Nurses should check the blood bag for any discoloration or clumping and also expiry date of the product.

Safe Collection:
The person/ relative who retrieve the blood from the bank must take a written evidence of patient’s identity. This must be check against the patient’s identification band exactly. Details of patients must include such as first name, surname, date of birth and unique identification number (BCSH 1999). It minimizes the risk of being wrong blood collected and giving it to the wrong patient.Transfusions on a Medicine Essay

Pre-administration check:
Pre-administration check is vital in ensuring safety measure while donating blood. It includes checking the patient information on the blood pack against the label of the recipient. The staff can enquire with the patients about their details and cross-check with the identification band. Due to ambiguity or unconscious state of recipient, identity can be verified with second staff member and via recognition band.Transfusions on a Medicine Essay

Based on compatibility report or patient’s note must not be considered as final checking procedure (NPSA, 2006). Nurse should remember the main 2 points.

No identification band – no transfusion, and always confirm with identity band.

The blood group and donation number on the compatibility tie-on tag should match the blood component.Transfusions on a Medicine Essay

If discrepancies are found during the process, the nurse should stop immediately and contact the transfusion laboratory. For example: DOB not matching with identity band. Continuity without distraction is important in verifying the information. In critical conditions, interruption can be allowed. Sometimes it makes them distract to perform checking from beginning to end.

Monitoring:
Studies show there are differing opinions of observing the patents during transfusion. It is generally agreed observations are recorded before administering. Rowe and Doughty (2000) highlights rate of response to reactions caused by blood without proper monitoring techniques. To respond quickly by the staff constant observation is mandatory.Transfusions on a Medicine Essay

Prior administration checking blood pressure, pulse rate and temperature is recommended (BCSH 1999). During the entire process for every 15 minutes the above recommendations are repeated. Making notes of vital signs for every 15 min is suggested during the first hour and every 30 min from second hour (Castledine 2006).

War strategists say that humans are likely to sleep in early hours of morning (3.00 am to 5.00 am). The sleep factor makes the observation bit difficult at night times. During delayed transfusion reactions being vigilant is challenging.

System factors:
System is defined as interaction with the physical, social and organization environment in which individual operate. It deals with Information technology devices, protocols, legal procedures, working environment, education and training etc.Transfusions on a Medicine Essay

Reducing the medical adverse drug events (ADE) at St. Joseph’s medical centre, Illinois has led to automation of process. The medication process is quite lengthy and incidents such as unavailable patient information, miscommunication of medication, labeling and storage are often repeated.

Information technology cannot replace the humans in critical care, but can reduce the repetitive tasks such as entering the pre-requisite details, including checks for problems. Humans are better than computers while taking complex decisions (Bates 2000). Reliance on individual is emphasized rather than automated systems when explaining errors and accidents (Parker and Lawton 2006).Transfusions on a Medicine Essay

CPOE (computerized physician order system) has made great impact in prevention of medication errors, while orders are written online. The information is structured, con