The early days (Musings on educating young TM professionals)

Updated: 18 Aug. 2015

August'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 
• Communication 
• Documentation 

Deaths (Worst transfusion-associated adverse event)
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?

In Canada it's now standard practice for physician offices to require photo ID, not just a provincial health care card. 

#2. ABO-incompatible red cell transfusions (pp.23,44)
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. 

SHOT gathered evidence that staff do not follow protocols and procedures and needs to investigate why.

• 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)

FURTHER READING

• SHOT 2014
• Full SHOT Report

As always, comments are most welcome.

Bridge over troubled water (Musings on what to be thankful for as TM professionals)

Updated: 4 Jan. 2020 (Updated song's link)

Apparently being thankful can improve your life. A professor of psychology at the University of California says so. It must be true (she wrote with tongue in cheek). Actually (and I hate writing or saying 'actually' after hearing a news reporter begin every sentence with it), I suspect it's true in most circumstances. Not necessarily when linked to being obsequious, though.

I had earlier written another blog for October on a topic I often blog about (two guesses - see below) but rethought it, especially since it's Canada's Thanksgiving today. Accordingly, this month's blog is about three things I feel thankful about it in the world of transfusion medicine and two that I don't.

Despite the Canadian references, transfusion professionals worldwide should be able to relate. As you read, I encourage you to think about your career and assess if any of my musings agree with yours.  Please feel free to comment.

The blog's title derives from 1970 Simon and Garfunkel classic, one of my favorites.

TOP THREE 'THANKFULS'

#1. Career in Transfusion Medicine
My life in TM began by accident and I never should have been hired. I was a high school teacher who wanted to work in Winnipeg but jobs were hard to come by for a 21 year old with a year's experience teaching in a rural Manitoba 4-room high school.

Lo and behold - a friend said, 'Pat, Canadian Red Cross Blood Transfusion Service hires BSc grads because most med lab tech grads from Red River Community College are scared to work there.' Say, what? I later learned the fear was largely because the clinical rotation was pathetic. Students spending most time labelling tubes and similar scut work in between being told by technologists to get the ABO group right or they could kill a patient. Did I mention the clinical rotation was only 2 weeks then?

Soon I started work in a large combined blood centre and transfusion lab, the latter doing compatibility testing for all city hospitals and beyond, plus prenatal testing for northwestern Ontario. At first, I did not even know what the yellow stuff was when the red cells settled. True story. Could never happen today, a good thing.

I'm so thankful for the mentoring of generous colleagues. And for wanting and needing to read the 'bibles' of TM from front to back (every word). The books were penned by such icons as Issitt and Mollison, and included the AABB Technical Manual and a 'little red book' written for Red Cross staff by Dr. B.P.L. (Paddy) Moore (and others), National Director of the Red Cross Blood Group Reference Laboratory, who died in 2011. I wrote about Dr. Moore in a 2007 blog, 'My life as a blood eater.'

I worked in Winnipeg for 13 years, got Subject certification in Transfusion Science (no longer offered) from what is now CSMLS. My last 3 years were as the clinical instructor for new laboratory staff, RRCC students, and medical residents doing a transfusion medicine rotation in the only show in town. How crazy is that?

Looking back, I'm thankful that I worked in a busy laboratory where you never knew what to expect. Besides the routine of pretransfusion testing for scheduled surgery and anemic patients, at any time 24/7 patients might need massive amounts of blood in a hurry from a ruptured aneurysm to a GI bleed to a placenta previa during delivery. Often the lab was chaotic but it was organized chaos, even if that's an oxymoron.

Moreover, I'm thankful that in those days work was mostly hands-on and issues arose daily that required problem solving. For example, I worked with Dr. John Bowman when he did the first trials of antenatal Rh immune globulin and was involved in the work that led to this paper (I'm the Pat mentioned in the paper):

• Lewis M, Kaita H, Anderson C, Chown B. Independence of Colton blood group. Transfusion. 1971 Jul-Aug;11(4):223-4.

Eventually the blood donor side of the laboratory got an autoanalyzer, the Technicon BG-15. We called it 'Big George' and two staff (probably closet chemistry technologists at heart) opted to become 'specialists in automation'. Can you see the irony?

For an absolute hoot, when you have some time for 'mindfulness' reading, see these articles from 45 years ago by Canadian Red Cross staff, including Dr. B.P.L. Moore. The second includes, 'The possible future role of automated tests on blood donations is briefly discussed.' (Emphasis is mine.)

• Moore BP. Automation in the blood transfusion laboratory: I. Antibody detection and quantitation in the technicon autoanalyzer. Can Med Assoc J. 1969 Feb 22;100(8):381-7.

• Meade D, Stewart J, Moore BP. Automation in the blood transfusion laboratory. II. ABO grouping, Rh and Kell typing, antibody screening, and VD testing of blood donations in the autoanalyzer. Can Med Assoc J. 1969 Nov 1;101(9):35-9. 

As to my career, the rest is history.... I'm thankful that I lucked out getting a teaching job in Medical Laboratory Science, University of Alberta, where I had the privilege of again working with generous, talented colleagues and teaching 100s of bright, inquisitive students, who kept me on my toes and forced me to keep learning. To be honest, at MLS I believe I had the best job teaching blood bank in the entire world.

Thinking about a career, particularly in later years, makes you realize how lucky you have been. I'm thankful to have worked in the trenches of blood banking doing work that made a difference and then to have gotten a job where that knowledge and skill could be passed to others. I hope that's true for you too.

As an aside, I'm thankful that I learned how to create web sites before it was easy (and you needed to know html code), which has stood me in good stead over the years, especially after I left real work. 

#2. Living in Canada
The good points of living in Canada are obvious, but that's not where I want to go. I imagine residents of many countries feel privileged for various reasons.

Instead, in keeping with the transfusion theme, I'm thankful that today Canadians are free to criticize CBS and our blood system leaders. Goodness knows, I do plenty of that and live to write another day.

October's TraQ newsletter has examples of criticism and responses to it:

• CBS tells staff that national blood inventory levels are at their lowest since 2008. In a Sept. 30 memo, Chief Supply Chain Officer Ian Mumford calls it a 'serious performance gap.' (Source: OPSEU blog, 6 Oct. 2014)
• CBS leadership should resign after admitting failure, says Ontario Public Service Employees Union president (OPSEU represents most CBS employees in Ontario)

• CBS apologizes for referring to homosexual sex as a 'behaviour.'
• Fascinating interview with Dr. Mark Bigham, Medical Officer, CBS Vancouver. 
• Full credit to Dr. Bigham for doing what must have been an awkward interview and not defensively arguing, as he could have, about what a 'behaviour' is or is not.

In olden days, medicine was so paternalistic that physicians had god complexes. Some still do but times have changed, not just among health professionals but between doctors and patients, as in this 2011 Maureen Dowd column in the NY Times:

• Decoding the God Complex 

In many countries criticism of perceived authority is not allowed. And in some democracies health care workplaces exist where questioning prevailing orthodoxy, especially by those lower in the pecking order, is discouraged, even risky, career-wise. I'm grateful that's not true in Canada's transfusion medicine community, at least not the one I've been fortunate to work in.

#3. UK's SHOT
The UK's haemovigilance scheme (why is everything in UK TM a 'scheme'?), known universally as SHOT (Serious Hazards of Transfusion), is a world leader in hemovigilance.

Note, I've dropped the 'ae' diphthong, which still rears its ugly head in Canada, a carryover from transplanted Brits running our blood system. (big grin).

I'm thankful for SHOT, a godsend to TM professionals globally and one of the best tools for education and quality improvement ever. As an educator, I use it repeatedly to make instruction real to students and professionals alike.

The prior blog discussed an example from the 2013 SHOT report on how errors occur and touted it as a great CE resource. 

• Stand by me (Musings on effects of errors on transfusion professionals)

I've mentioned SHOT again in order to emphasize one of the 'Bottom Two' issues below that I'm NOT thankful for.

One of the best parts of SHOT's reports are its case studies, which detail exactly what went wrong and provide learning points. As but one example from SHOT 2013:

• Case 3: ABO incompatible transfusion despite a robust system of warning alerts on the laboratory information management system (LIMS)
• Search for 'Case 3' (without the quotation marks)

Excerpt:

" An ABO incompatible red cell unit was transfused resulting in a haemolytic transfusion reaction. The blood was issued using an emergency protocol on the LIMS, which was not appropriate for the non-urgent clinical situation, and the computer warning flag stating that the units were incompatible was overridden several times by the biomedical scientist (BMS).

This incompatibility was not noted at the bedside and when the patient reacted to the transfusion, the doctor who was consulted advised that the transfusion should continue without reviewing the patient. The patient developed acute and delayed haemolysis, but no long-term sequelae."

Good stuff, no?

TWO NOT-THANKFULS
To give the blog a dash of hard cold reality and move from 'Kumbaya' territory, two TM realities I'm not grateful for:

NOT Thankful For #1
Canada's lack of a hemovigilance reporting similar to SHOT, where TM practitioners and educators alike, can see how our TM system is doing. Oh wait! Instead of the usual archived SILENCE, all of a sudden, TTISS is online with  - wait for it - summary tables:

• Transfusion Transmitted Injuries Surveillance System (TTISS) Summary Results for 2006 - 2012

Okay, I guess we should be thankful for small mercies. We're keeping statistics, so will be able to measure improvement. And finally a public report on all the data that's been collected, even though no news media have picked it up, hence no citizens will even know. Plus, no real details, no analysis. Baby steps...

For interest, I blogged about Canada's lack of hemovigilance reporting in 2011:

• Only in the UK and 'Down Under'? Pity! (Musings on hemovigilance)

NOT Thankful For #2
Health Canada's stonewalling on Ontario's paid plasma clinics. I've blogged about this many times. HC's public consultation from April 2013 has transmogrified into SILENCE as 2015 approaches. Hmmm...

The one thing perhaps to be grateful for is the hope that 'no news is good news.' Not holding my breath.

LEARNING POINTS
1. I hope all readers can say they love their careers as I love mine. In some ways the 20th C was a golden age, especially for those of us who love immunohematology.

Work is something we do, first to provide essentials like shelter and food, second to be able to appreciate the good things in life that aren't free, and third, to make a difference in the world - to make life better for each other.

TM professionals are truly fortunate to love going to work each day and to be able to question authority. For so many on the planet that's not true. Best of all is knowing we make a difference, each in our small way. It's captured by Mary Oliver in her poem, The Summer Day:

'Tell me, what is it you plan to do

with your one wild and precious life?'

2. Where we live is an accident of birth. We in the industrialized west are so fortunate. Search Google's images for 'children garbage dumps' for  1000s of examples. Or people who say homosexuality should be accepted or places where female genital mutilation commonly occurs.

3. Some national blood systems spend time, energy, and money on improving transfusion practice and generously share it with the rest of us. The best example is SHOT, funded by the UK Blood Services. Kudos to NHSBT. Wish Canada and the USA would do more of the same. Hope springs eternal...

FOR FUN

What was my original Oct. blog's topic? Two guesses (my favorite 'hobby horses'):
A. Paid plasma clinics
B. HIV/AIDS
For  clue, look at TraQ's Oct. newsletter.

Now, on to the fun music selections. On the two TM issues I'm NOT grateful for, the song that comes to mind is Simon and Garfunkel's 1964 classic, 'The Sound of Silence,' #156 on Rolling Stone's list of the 500 Greatest Songs of All Time and one of the most covered songs of the 20th C.

• The Sound of Silence (Simon and Garfunkel, Live in Central Park, 1981)

On the three TM realities I am grateful for, the chosen song is another Simon and Garfunkel classic, 'Bridge Over Troubled Water' released in 1970, ranked #48 on Rolling Stone's list of the 500 Greatest Songs of All Time.

Why? Mainly because I'm grateful for this song and appreciate its lyrics.
Also, because one of the best things in life is to be grateful for our friends.

• Bridge Over Troubled Water  (Simon and Garfunkel, Live in Central Park, 1981)

When you're weary, feeling small,
When tears are in your eyes, I will dry them all.
I'm on your side. When times get rough
And friends just can't be found,
Like a bridge over troubled water
I will lay me down.

As always the views are mine alone and comments are most welcome. Does any of this ring true? What are you grateful for these days?

Added 25 Nov. 2014

In reply to Anonymous, who notes Globe and Mail article:

• Canadian Plasma Resources gives up on plan to open plasma clinics in Ontario (24 Nov. 2014) and comments
• "I don't understand how they could pull out but still hope to continue drawing plasma for research purposes. It would be interesting to see the protocol and Informed Consent on this proposal."

Another article from Toronto Star on the news:

• Paid plasma company takes $400 million expansion out of Ontario (24 Nov. 2013)

Seems CPR will try to open paid plasma collection centres in western Canada, likely BC or Alberta [vs Saskatchewan or Manitoba, where a paid plasma clinic exists in Winnipeg, but for plasma containing special antibodies, e.g., anti-D to produce Rh immune globulin)] because of their larger populations and openness to private medical facilities.

About CPR collecting plasma for research purposes in Ontario, I agree it would be interesting to see the protocol and informed consent for such a proposal. Thanks for the comments.

Added 3 Nov. 2014

In reply to Anonymous, who writes about introducing paid plasma clinics in Ontario:

• "Policy decisions of this nature should not be made without hearing from those who are affected the most by the legislation: that is, the recipients of plasma-derived medicinal products represented by their associations”:

For reference, PPTA is Plasma Protein Therapeutics Association. PPTA represents the private sector, collectively known as plasma protein therapies and the collectors of source plasma used for fractionation. In other words, PPTA represents a part of Big Pharma whose business involves collecting, manufacturing, and selling blood-derived plasma products.

The link provided by Anonymous is to a paper in the Fall 2014 issue of The Source, a PPTA publication:

• 'Compensation for Plasma Donation in Ontario: A Cautionary Tale' by David Page, National Executive Director of the Canadian Hemophilia Society 

Page's article is PRO PAID PLASMA (my interpretation): Today's products derived from paid plasma  are safe and all user groups want paid plasma because they buy the premise that, without it, their lives are at risk.

Interesting that PPTA's Fall 2014 issue of The Source includes David Page's article, as well as an article by CBS CEO Graham Sher:

• CBS's viewpoint 

Dr Sher's take home message is the same as he's espoused in Canada;

• [Paid plasma] is an issue of public policy, not product or patient safety.
• Pharmaceuticals made with plasma from paid donors are safe, lifesaving products for patients in Canada and around the world.
• Canadian Blood Services remains committed to voluntary donation for its donors.

Sher's article is PRO PAID PLASMA (my interpretation): Because paid plasma is safe, to use it or not depends on government policy.Without paid plasma, people would die. But, hey, CBS is committed to a voluntary blood system. 

The PPTA would not publish articles that were anything but PRO PAID PLASMA. 

Further Reading

• The Source, Fall 2014 (Industry publication)
• The twisted business of paid plasma (The Atlantic, May 2014)
• Earlier blogs on paid plasma (Search at top left for 'paid plasma') 

Stand by me (Musings on effects of errors on transfusion professionals)

Updated: 9 Sept. 2014

Recently, I browsed the Speaker abstracts and Poster abstracts for the BBTS annual conference to be held 24-26 Sept. in Harrogate, UK. The abstracts were published online 26 August 2014 as free full text. At the same time, I happened to be reading the UK's 2013 SHOT Report published in July. One abstract and a section of the 2013 SHOT coalesced to form the idea for this blog.

September's theme relates to all transfusion professionals, whether lab technologist/scientist, nurse, or physician. The blog’s title derives from a 1961 song by Ben E. King, covered more than 400 times and featured in a 1986 movie of the same name.

Of all the fascinating BBTS abstracts, the one chosen to build a blog around is under 'Clinical Audit/Service Improvement Short Paper Orals':

• SI27. An exploratory research study into the effects of staff feelings and perceptions following a transfusion incident investigation. Transfus Med 2014;24 (Suppl. 2):19. 
• By D. Creighton (SNBTS Edinburgh) and M. Wright (Glasgow Caledonian University, Glasgow)

The reason this abstract resonates is that in a long career as a lab technologist, supervisor, and educator I've been involved with and privy to many serious transfusion errors and their effects on the professionals involved.

What follows are my musings on the BBTS abstract and related personal memories, as well as what the 2013 SHOT Report says about causes of human error. The focus is on the effects that errors have on those who make them, realizing that it is patients who suffer irrevocable, sometimes fatal, consequences.

As an aside, with a background as a medical laboratory technologist (biomedical scientist) and transfusion science educator, what I like about the 2014 BBTS meeting is how many talks and posters directly relate to transfusion professionals who work in the laboratory.

2014 BBTS MEETING ABSTRACT
As noted, the abstract that stimulated the blog is by D. Creighton and M. Wright of the SNBTS Edinburgh, and Glasgow Caledonian University, Glasgow, respectively. Please read the complete abstract (Further Reading). My précis of it is as follows:

• Most research on transfusion errors focusses on procedural errors, not human factors or staff emotions. This research examined the emotional impact of errors and contributing factors.
• Researchers recruited and interviewed staff involved in a transfusion error and analysed results.
• Of 12 staff, five agreed. The main human factors acknowledged by four participants were distraction and a busy work environment when the error occurred. 
• All five expressed disbelief they had been involved.
• Four were affected emotionally, experiencing insomnia and decreased confidence. 
• Most worried about confidentiality and other staff knowing they’d made an error. 
• Support was mainly positive but two participants experienced negative reactions from colleagues. 
• All learned lessons which they would carry forward and share with colleagues. 
• Participants’ reactions directly correlated to error severity and potential patient outcome.

The authors conclude that human factors need to be included in training packages. Reactions and feelings of staff involved in errors can be overwhelming and support is crucial.

MUSINGS
With the advent of quality systems and hemovigilance, transfusion medicine has long had a no-blame culture (at least in theory), as have health care systems in general. For example,

• Patient safety and quality: An evidence-based handbook for nurses. (2008) Chapter 35. Error reporting and disclosure

• Developing a platform for learning from mistakes: changing the culture of patient safety amongst junior doctors. BMJ Qual Improv Report 2014;3.

A no-blame culture is critical for patient safety. Health professionals must feel comfortable with reporting errors, including their own, so that hemovigilance and quality improvement programs can detect, analyse, and help prevent them in future. In an effort to encourage error reporting, we use blame-free terms such as events, incidents, and occurrences. Despite the talk, 'walking the talk' of no-blame attached to individuals who make errors is a tough slog.

PERSONAL MEMORIES
Below are two memories of transfusion-related errors I was involved in with serious consequences.

Memory #1 
Years ago when working in a combined centralized transfusion service/blood centre, one weekend when on shift by myself, I crossmatched a group AB patient for several RBC. The following Monday I was also working when the call for more blood came through. We had to order a new specimen as there was no more patient serum. (Yes, in olden days we routinely used clotted blood samples for pretransfusion tests and even patients without clinically significant antibodies were crossmatched by indirect antiglobulin test and more.)

Much to my horror the patient now typed as group O. I’m sure my entire insides shook as a colleague redid the patient’s ABO on the earlier sample. Absolute personal relief when it typed as group AB.

The transfusion service did the usual follow-ups. Called to stop any transfusions, asked how many RBC had been transfused and if patient was experiencing any signs and symptoms of a hemolytic transfusion reaction, requested new blood specimens, etc.

The patient experienced a severe hemolytic transfusion reaction but survived.  It’s amazing how resilient the human body is, even for those ill enough to be transfused:

• Janatpour KA, Kalmin ND, Jensen HM, Holland PV. Clinical outcomes of ABO-incompatible RBC transfusions. Am J Clin Pathol. 2008 Feb;129(2):276-81.

We later learned that a hospital nurse had drawn the blood specimen from the wrong patient. Both the group AB and O samples came from patients in the same hospital room. And the RN in question was the highly respected liaison we dealt with at that hospital, the one who drew many of the blood samples and maintained the onsite ‘blood bank’ (refrigerator and associated request forms and records).

The effect on the implicated RN is unknown. Was the patient's family told what had happened? I doubt it. The effect on me - I’ll never forget it. 

If I had mistyped the first specimen, would I have been fired, even though it was the first ‘critical incident’ (or any error) I’d been involved in? Perhaps. That was a long time ago, pre-quality systems, when the concept of ‘system error’ was unheard of in health care. We were not unionized and worked long (indeed outrageous) hours without time off.

But before being fired, I suspect that I’d have resigned from the guilt and shame of having made the biggest error a lab technologist can make, mistyping a patient’s ABO group and putting a patient's life at risk. Because ABO errors can cause death, they require 100% accuracy, no room for error. Could counselling have helped? Maybe. Even more important would be the support, understanding, and ongoing respect of colleagues.

Of interest, the 2013 Annual SHOT Report reports 9 ABO incompatible red cell transfusions in 2013 and one patient death with the incompatible transfusion as a contributory factor.

Memory #2 
Much later, while employed as a university professor and clinical instructor for the transfusion service at a tertiary care hospital, one of my students made an error that caused a patient’s premature death. The error per se did not cause death but hastened it.

What was the error? Something so simple. Something that can happen if concentration wanders, or strategies are not in place to prevent them, or practitioners don’t follow procedures.

While performing antibody screens, the student mis-pipetted one patient’s serum into another patient’s tests. As a result the patient was transfused with incompatible red cells and subsequently died. I documented the error as a TraQ case study for the BC Provincial Blood Coordinating Office.

Although not directly involved with the error (the student was supervised by an experienced, exemplary technologist), I observed the aftermath first hand. The main effect was that the experienced, supervising technologist, one of the best, with great potential, soon left the lab for a career outside health care. Could this have been prevented? With proper support, I believe so.

• TraQ's Case A8: Severe Hemolytic Transfusion Reaction Involving a Student (see Further Reading)

MAKING MISTAKES
When we make mistakes, our first reaction is to deny them. For example, as an instructor I noticed that students who made pipetting and other mistakes would invariably claim something like, “I KNOW I added the right things’, where ‘things’ could be patient serum, reagent red cells, etc. My response was always,

• ‘Of course, you thought you were adding the right things to the tests. If you knew you were adding the wrong things, you’d stop and would not add them.’ 

Fortunately, because such errors are often easy to demonstrate, students could accept their errors, learn from them, and move on.

Sometimes, especially as students, we progress to blaming circumstances for our errors. And sometimes circumstances do play a role as when staff are overworked, morale is poor, and training and competency assessment are inadequate. These are the so-called system errors where the system is faulty and affects all involved.

2013 SHOT REPORT
A fascinating feature in the 2013 Report is the inclusion of the MHRA hemovigilance team's analysis of serious adverse events (SAEs) reported to Serious Adverse Blood Reactions & Events (SABRE).

• Medicines and Healthcare products Regulatory Agency (MHRA) Report on Blood Safety and Quality Regulation in 2013 (See pp. 27-41)

In 2013, 2.9 million blood components were issued in the UK with only 705 SAE reports submitted. Human error accounted for 689 (97.8%) of the SAEs, where an SAEs is defined as

‘Any untoward occurrence associated with the collection, testing, processing, storage and distribution, of blood or blood components that might lead to death or life-threatening, disabling or incapacitating conditions for patients or which results in, or prolongs, hospitalisation or morbidity.’

In brief, reports to SABRE showed that those making errors were aware of their local SOPs, which were complete and current. Individuals were either busy with urgent work when the error occurred (especially during out of hours shifts), or were otherwise distracted. In either case the result was an error due to a lapse in concentration.

Of all reported human errors, a lapse in concentration was the largest single cause, accounting for 35.6% (245/689) of errors. The next largest category related to omitting procedural steps or not following the correct procedure. About two thirds of all SAEs could have been prevented had correct procedures been followed.

The advice that especially caught my attention in the MHRA report:

• Formal re-training is often proposed as a corrective measure but is usually only appropriate if the individual did not understand their initial training. If a trained, competent member of staff makes an error, the root cause will seldom, if ever, be addressed by re-training. 

• Look for other reasons for the error, e.g., for an error due to loss of concentration when rushing, investigate why the staff member was rushing. Possible causes include a busy workload due to an emergency, poor planning, staff shortages due to lack of resources, or poor staff management

Being rushed is a reality for health professionals, now more so than ever. A major complicating factor has long been staff shortages and under-staffing caused by repeated health care restructuring, ongoing cutbacks to postsecondary education and health care, and more.

LEARNING POINTS
When errors happen, we in the TM community espouse a ‘no blame culture’. Sometimes it’s real, sometimes it’s pretence, in that, despite the nice words, staff are blamed and stigmatized.

But as the BBTS meeting abstract shows, we typically don’t consider the emotional effects of making errors on those involved. It’s all cool root cause analysis, perhaps targeting ‘system error’ as the culprit, but more often resulting in ‘training issue’ as the catchall for whatever goes wrong.

How the staff involved feel is seldom considered and, besides re-training, their emotional well being is largely ignored. At most a caring colleague might ask, 'Are you okay?' with the individual involved seldom replying honestly.

No-blame culture aside, making errors devastates health professionals and undermines confidence.  In some ways, that’s preferable to brushing off errors with, ‘Oh well, sh*t happens’. But without support, a serious error can have long-lasting negative effects on individuals and co-workers alike. Even well meaning colleagues may be critical, never overtly express it to those involved, thinking it could never happen to them, or secretly thinking, ‘Thank gawd that wasn't me!’

A critical issue is that we acknowledged making errors as human. If we haven’t made one yet in the lab or on the wards, we likely haven’t worked long enough. Or is it that we are perfect? Hmmm…. Tempted to say, ‘Let he who is without sin [error], cast the first stone.'

In that vein, I love this BMJ piece:

• "I don't know": the three most important words in education (British Medical Journal, 8 May, 1999).

As an instructor I tried to model these words to show students it’s okay not to know. Who can know everything with today’s rate of knowledge turnover and technological advances? Don't know? Let’s find out.

Maybe we should add, ‘I made a mistake’ as three words we acknowledge but don’t let define or destroy us.

FOR FUN
We’re all in this world together and must support each other, especially when the going gets tough. As health professionals, any one of us is capable of making a devastating error. Support and compassion are not only kind but validate our humanity.

Think of this song the next time a colleague screws up. Could be you, yes it could.

• Stand by me (Ben E. King)

I'll end by asking you to find 19 minutes to watch Dr. Brian Goldman's TED talk on physician error. That may seem a lot of time in our busy lives but think of all the time we waste on the Internet and television each day. You won't be disappointed with Goldman's talk. His message applies to all of us. Perhaps you can listen to it on your next walk or jog or over lunch?

• Doctors make mistakes. Can we talk about that? (19 Min. TED video - highly recommended)
• Canada’s Brian Goldman is an ER physician in Toronto, and the host of CBC Radio’s "White Coat, Black Art" and 
• Author of The Secret Language of Doctors

As always the views are mine alone and comments are most welcome.

FURTHER READING
Meeting abstracts and resources like SHOT reports and TraQ's case studies are free continuing education and a great way to keep abreast of new developments and what’s trending. They make great bathroom (toilet/loo) reading to while the time away so that life’s baser functions serve a higher purpose.

Why not skim them online and then print content of most interest for later reading? Or print for discussing at staff meeting or journal clubs. Do journal clubs even exist any  more?

• BBTS 2014 Annual Conference abstracts
• Speaker abstracts 
• Poster abstracts
• TraQ's Case A8: Severe Hemolytic Transfusion Reaction Involving a Student
• 2013 SHOT Report
• Medicines and Healthcare products Regulatory Agency (MHRA) Report on Blood Safety and Quality Regulation in 2013 (pp. 27-41)

Only in the UK & Down Under? Pity! (Musings on hemovigilance)

The UK's Serious Hazards of Transfusion (SHOT) report for 2010 became available in the summer, and I thought a blog on its key findings was in order before 2011 ends.

As I got into it, I realized that something was amiss. Such reports simply do not exist in my own country (Canada) nor the USA, with which we share the longest border in the world between any two countries.

The blog's title comes from an old, iconic Red Rose tea commercial in Canada. Only in the UK and Down Under refers to the English-speaking world.

As most transfusion professionals know, SHOT, established in 1996, is the mother of all hemovigilance schemes and an exemplary example of transparency for blood transfusion systems worldwide.

It's also worth noting that blood transfusion in the developed world is safer than ever. When you examine hemovigilance reports you realize that Pogo was right. We have met the enemy and he is us.

Despite improved screening to prevent transfusion-transmitted diseases and the tainted blood tragedies of the 80s and 90s, and despite the massive effort to implement quality systems, we humans remain the challenge. The education and training of all health personnel is the single most crucial QSE.

SHOT 2010

Like all hemovigilance schemes, SHOT IS voluntary and gathers and investigates reports of adverse events, near misses and physiological reactions that may be linked to transfusion. Investigation of reported cases generally concludes, based on available evidence and its quality, that the adverse event (interpretations are mine)

• Had little if anything to do with transfusion (no evidence)
• Possibly resulted from transfusion (low-level evidence)
• Likely resulted from transfusion (good evidence but inconclusive)
• Definitely resulted from transfusion (strong evidence)

So, what are the highlights of SHOT's 2010 report?

DEATHS

The worst first. SHOT 2010 includes 13 transfusion-related deaths, 3 in which transfusion directly and solely ('definitely') contributed. The putative contributory causes include:

• TACO: 6 (1 definitely, 3 likely, 2 possibly)
• ATR (acute transfusion reaction)*: 3 (1 definitely, 2 possibly)
• HTR (hemolytic transfusion reaction): 1 (definitely)
• Under-transfusion: 1 (possibly)
• Delayed transfusion: 1 (possibly)
• TRALI: 1 (possibly)

* ATR: Acute reactions occurring up to 24 hrs post-transfusion, excluding cases due to IBCT (incorrect blood component transfused), HTR, TRALI, TACO, TAD (transfusion-associated dyspnea) and bacterial contamination.

MAJOR MORBIDITY

As well there were 101 cases involving major morbidity, 57 of which were classified as acute transfusion reactions.

CLASSIFICATION

Classifying cases is complex since adverse events and errors can be classified along multiple lines. Overall, of the 1464 cases in SHOT 2010, most (88.8%) fell into these categories:

• Acute transfusion reaction: 510 (34.8%)
• Involving anti-D immune globulin (RhIg): 241 (16.5%)
• Handling and storage errors: 239 (16.3%)
• Incorrect blood component transfused: 200 (13.7%)
• Inappropriate, unnecessary, under or delayed transfusion: 110 (7.5%)

Another way to look at incidents and cases is to assess if they originated in clinical areas or transfusion service laboratories. I encourage you to read these sections of the report, which contain many valuable tidbits, or 'learning points' as the report calls them. Two examples:

 Clinical: Lack of correct final identity check leads to an HTR (p. 21)

A patient with a haematemesis was in need of an urgent blood transfusion. The patient’s wristband was contaminated with blood and could not be read, and as a consequence the electronic bedside checking system was not used. The compatibility form filed in the patient’s notes, which belonged to another patient, was used to provide the identifiers for collecting the blood. The patient, who was group O RhD positive, was transfused with >50 mL of A RhD positive red cells prior to the error being recognised. The patient was admitted to ITU with intravascular haemolysis and renal impairment. 

Laboratory: Cord blood group allocated to wrong computer record, resulting in delay in administration (p. 65)

A cord blood group was correctly tested as RhD positive, but the result was erroneously uploaded to the maternal record on the laboratory computer system by a shift BMS [lab technologist] who did not normally work in transfusion. The error was only spotted when the clinical area enquired as to why there was no cord group available and why the maternal group was now showing as RhD positive.

For fun: Related to incorrect blood components transfused, guess which area (clinical or laboratory) decreased its errors most compared to 2009. (Answer on p. 1 of the report)

DOWN UNDER

Both Australia and New Zealand have active hemovigilance systems that publish detailed public reports.

Australia

Australia produced its first report in 2008. The 2010 report deals with transfusion errors and adverse events that occurred July 2008–June 2009. The Oz hemovigilance system is not as mature as the UK system (no system is, at least in the English-speaking world) but the clear reporting and detailed case studies make for fascinating reading.

• 2010 National Haemovigilance Report (National Blood Authority)

New Zealand

The Kiwis produced their first report in 2005 and have a more advanced system than Australia's. For example, the NZ 2009 report includes antibodies involved in delayed hemolytic / serologic reactions and also donor adverse events.

For fun: Guess which two antibodies lead the delayed transfusion reaction list? (Answer on p. 24 of the report)

• National Haemovigilance Programme 2009 Report

USA

The USA's Biovigilance Network was initiated only in 2006 and, so far as I know, has yet to publish public reports similar to SHOT, although data for individual diseases such as Chagas are available to AABB members.

• US Biovigilance website (part of AABB's site)

Of note, before 2006 the USA was one of the only developed countries in the world without a national hemovigilance program, just as it's one of the few without universal health care.

CANADA

What about my own country? On paper we seem to have a national hemovigilance system called TTISS but upon closer examination TTISS appears to be smoke and mirrors.

For example, the last published TTISS report available on the PHAC website is the

• 2004-5 TTISS report (and then only published in 2008)

What gives? Either we have a national hemovigilance system or we don't. Is it another case of phantom transfusion committees that meet now and then to document they exist but never really do anything of substance?

Did the federal government decrease PHAC money at some point, so that it could not implement original plans for the hemovigilance system? Did PHAC decide hemovigilance was low priority compared to other public health issues?

Who knows? It's never discussed. Everyone just pretends.

Whatever the reason, Canada's blood system leaders may pretend that the emperor has new clothes, but it seems that TTISS has no clothes, much like Hans Christian Andersen's emperor.

Provincial government blood coordinating offices have TTISS programs and routinely state on their websites

• Data are disseminated regularly to stakeholders through TTISS Program Reports.

Really? The links go to the PHAC site with the most recent report the one for 2004-5. To call them 'reports' is farcical as they consist of an introduction and table of contents. Who is kidding who?

BOTTOM LINE

Kudos to the UK, Australia, and NZ governments and their respective blood systems for stepping up to the plate with hemovigilance.

But why do Canada and the USA lag behind when it comes to hemovigilance?

 You can somewhat understand the USA situation. Unlike most countries in the developed world, it has a competitive, fragmented blood system involving multiple players.

As well, hemovigilance systems elsewhere are largely funded by governments, something some Americans on the right (or maybe even most Americans) equate with "socialized medicine" or worse, i.e., supported by delusionary 'commie pinkos' (big grin)

Still, the USA has a well developed blood system and it remains the richest country on earth. That its hemovigilance system is barely off the ground in 2011 is worrisome, if not to say pathetic.

But Canada's TTISS is inexplicable. Frankly, I'm embarrassed that we pretend to have a national hemovigilance system when we don't.

Maybe it's not that surprising. When it comes to hospital-based transfusion services, the feds have always employed smoke and mirrors.

In the early 2000s there was a big kerfuffle about government regulation of the blood system extending beyond blood suppliers to transfusion services. I even wrote about it:

• 2004 Letendre P. CSA Standards Z902-04:implications and issues. Blood Matters 2004 Jul;6(3):1–4.

At the time the TM community believed that CSA Standards applicable to transfusion services would become government regulations within approximately 2 years. That did not happen and has not happened yet, 7 years later.

We do not know why, but I suspect it's the government wanting to save money combined with a belief that transfusion service regulation is low priority, given that transfusion services must comply with standards to be accredited by provincial colleges of physicians and surgeons. This viewpoint may or may not be a valid argument.

But why the smoke and mirror pretence about hemovigilance? It's cheating. Makes me wonder what other deceptions our blood system leaders are conning us with.

JUST FOR FUN

Some golden oldies that seem to fit the federal government's modus operandi:

• Your cheating heart (Patsy Cline)
• The great pretender (The Platters)

Will those responsible ever say "I'm sorry"? I doubt it.

• Who's sorry now (Connie Francis)

ADDENDUM

15 Nov. 2011: Just read an editorial in the Dec. issue of the BBTS journal, Transfusion Medicine:

• Roberts DJ. Public policy, blood safety and haemovigilance. Trans Med 2011; 21(6):357-8. Pub. online 14 Nov. 2011.

The editorial discusses the focus of the Dec. issue, i.e., SaBTO's recommendations on

• accepting male blood donors who have had sex with men;
• desirability and practicalities of obtaining formal consent for blood transfusion.

The author concludes:

"Both these recent decisions and the means to implement them depend directly or indirectly on a good quantitative analysis of the risk of blood transfusion. There could be no better illustration of the practical importance of reliable and comprehensive haemovigilance schemes. Establishing and maintaining such systems must be a priority for the development of safe and effective transfusion and transplantation services globally."

As usual, the opinions are mine alone. Comments are most welcome.

Further Reading

UK

SHOT 2010 Educational Symposium (14 Oct. 2011):
"Transfusion - Are we over-reacting?" (Alison Watt, SHOT Operations Manager)

Stainsby D, et al. Serious hazards of transfusion: a decade of hemovigilance in the UK. Transfus Med Rev. 2006 Oct;20(4):273-82.

Canada

Global shift towards increased biovigilance surveillance system. (CMAJ 2010. DOI:10.1503/cmaj.109-3195).

Pilot projects lay foundation for national tissue surveillance and traceability system

GLOBAL

Hemovigilance worldwide

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