Upfated: 18 Aug. 2015August's blog was stimulated by the UK's Annual SHOT Report, which has featured in past blogs many times. SHOT has long been the best hemovigilance program anywhere and is a treasure trove of educational goodies we can all learn from.
Since it's summer in the northern hemisphere, when many transfusion professionals will be enjoying the outdoors of our all too short summers (at least in Canada) the blog will consist of selected mini-musings on 2014 SHOT.
The blog's title derives from a song by Canadian folk singer/song writer, Chris Luedecke, known professionally as 'Old man Luedecke".
2014 SHOT - SELECTED HIGHLIGHTS
For perspective, in 2014 there were 2,663,488 blood components issued in the UK (74% RBC). SHOT received reports of 3668 cases or 13.8 reports per 10,000 blood components.
The following are but a few of my personal highlights. See Further Reading for the full SHOT Report.
Overview (What causes adverse events?)
In 2013, 77.6% of all incidents reported to SHOT were caused by errors & it's similar in 2014.
There is increasing concern about the impact of reductions in numbers and seniority of staff in the NHS.
SHOT 2013 reported that many, often multiple, errors are made during the transfusion process and data from 2014 were analysed similarly. As well, adverse events are grouped into 3 main categories. Failures relate to
- Patient identification
In 2014, there were 2 deaths definitely attributed to transfusion, 1 hemolytic transfusion reaction and 1 transfusion-associated circulatory overload (TACO). Delayed transfusion contributed to 3 deaths.
ABO-incompatible RBC transfused (Key because ABO mismatches can lead to patient death, major morbidity)
N=10 (0 deaths, 1 major morbidity). This compares to 9 in 2013 and 12 in 2012. All were due to clinical (not laboratory) error.
Near misses (Avoiding major patient consequences often due to luck)
Wrong blood in tube accounted for 686/1167 (58.8%) of all near misses, where a near miss is defined as,
"Any error, which if undetected, could result in the determination of a wrong blood group or transfusion of an incorrect component, but was recognized before the transfusion took place."MUSINGS
Below are musings on a few highlights in SHOT 2014 (edited for brevity). Some caught my imagination because they were odd, and some involved serious adverse events.
#1. False Identity (p. 45) describes several cases where the 'patient' is responsible for giving false identity. For example:
Case 2: Staff member involved in deliberate identity fraud
A blood group did not match the patient's historical record. Concurrent Haematology and chemistry samples were rejected and repeats of all samples requested.
Investigation revealed that test requests were initiated by a staff member. Samples were from a family member but labelled with the staff member's own details. The staff member returned to work after suspension and re-training.
Musings: A similar case occurred years ago at UAH in Edmonton, where a medical resident labelled his own blood sample as that of a patient in order to discover a particular lab result. To my knowledge he was given a bollocking and educated on why this was NOT a good idea.Case 3: Pregnant woman conceals her identity
- A 24 year old woman had an ultrasound scan at a hospital where she was advised to terminate a pregnancy.
- The patient attended another hospital giving a friend's name for identity but her own father as next of kin.
- She had a surgical termination which was complicated by
- Massive haemorrhage requiring transfusion with RBC, FFP, and cryoprecipitate;
- Emergency intervention and uterine artery embolisation;
- Followed by admission to the intensive therapy unit , all at the first hospital.
- When her father was called in he confirmed she was his daughter but that the name on her wristband was not hers.
Musings: Years ago, when I worked in Winnipeg for the then Red Cross centralized transfusion service/blood centre, a similar case occurred. I crossmatched blood for a young woman having a therapeutic abortion. She had assumed the identity of her friend, who just happened to have a blood group on record.
Interesting that patients providing false identity still exists. It likely occurs much more often than we know because we only catch the ones where the 'false patient' has a prior blood group record or the real patient requires blood in the future.
I also wonder about false identity in the USA where universal health insurance doesn't really exist yet. Do people who lack insurance for a needed procedure use a friend's identity?#2. ABO-incompatible red cell transfusions (pp.23,44)
In Canada it's now standard practice for physician offices to require photo ID, not just a provincial health care card.
As noted earlier, of 10 ABO-incompatible red cell transfusions, all were caused by clinical (not laboratory) errors.
- In 7/10 cases there was a failure in correct patient identification, with no bedside checks performed.
- Actions taken varied but in one case 2 nurses were dismissed, in others staff were supported, retrained and their environment modified.
- In 7/10 clinical errors, group A RBC were transfused to group O patients
- 2 were transfused in emergencies, 3 others were 'urgent'
- One event occurred in a young woman during a liver transplant. The group O patient was bleeding and a new anaesthetist, who was an observer, 'helped' by taking the unit of blood from the refrigerator and transfused it. It was group A blood.
- The OR practitioner noticed the error when less than 50mL had been transfused.
- The patient died from complications following respiratory arrest.
- Root cause analysis resulted in several changes to surgical procedures.
Musings: It's amazing that 7/10 wrong ABO transfusions involved failed patient identification, with no bedside checks performed by clinical staff (presumably mainly RNs but including Drs, as in the case of the anesthetist described above). Unsurprisingly, most (5/7) occurred with urgent transfusions.
In the one case where 2 nurses were dismissed, I wonder if their errors were the final straw in a list of major errors. Because firing staff does not fit with today's no-blame culture of support and retraining, as occurred in other cases.
As SHOT notes, when health professionals do not follow established procedures and protocols, we need to identify why to prevent future occurrences.#3. Most adverse events caused by error
SHOT documents that in 2013 and 2014 more than 75% of all incidents were caused by errors and expresses increasing concern about the impact of reductions in numbers and seniority of NHS staff.
Musings: Cutbacks and increasing numbers of senior staff retiring are concerns worldwide. Remaining staff are overworked and often lack needed experience and expertise.
Unfortunately, few senior staff exist to mentor them and share the practical knowledge and skills absent in journals and textbooks. That's if remaining staff even have time to read and consult them.FOR FUN
Although Canadian Chris Luedecke's touching song 'The Early Years' is about his children and family life, it resonates with me from a professional perspective. Listen to the lyrics. They're delightful.
In today's health care environment, despite many obstacles, educators must lead by example and take time to educate and train young transfusion professionals to instill values that ensure the next generation puts patient safety above all else. Knowledge and skills, of course, plus clear rationales for all those pesky 'rules' are key.
But ultimately it's DNA-ingrained ethics that protects patients so that even overworked, busy health professionals meticulously follow established SOPS such as routinely and always checking patient identity.
Fact is, those early days when we train the next generation, they don't last. We must get 'em while the gettin' is good.
You got to hold on,
It goes so fast
These early days, well,
They don't last.
You got to enjoy [train] them.
They go so fast.
The baby days, well, they don't last.
- The early days (Old Man Luedecke)
As always, comments are most welcome.