The stage of great risk in the transfusion chain is the collection of the component from the blood bank or satellite refrigerator and its administration to the patient. Errors at these stages constituted 40% of ‘‘wrong blood’’ events reported to SHOT in 2003 and resulted in 12 ABO incompatible transfusions. Anecdotal case reports provide insights into the system failures. Inaccurate verbal instructions and the common pitfall of similar patient names can contribute to blood issue and administration errors. Of cases reported to SHOT in 2003, 10/45 patients for whom the wrong blood was collected from the blood bank and subsequently administered at the bedside were undergoing urgent or massive transfusions in critical care environments, such as operating theatres, recovery suites, emergency departments, intensive care units or delivery suites. Adverse events reported to SHOT are analysed to identify individual contributory errors. Consistently, the most common error in successive reports (27% in 2003) is a failure to carry out an adequate pretransfusion ‘bedside’ check. In the majority (87%) of adverse events in which the bedside check failed, a previous error might have been detected at this stage but was not, while in the remainder, the first and only error resulting in blood being given to the wrong patient was made at this final and most critical stage in the process. Contributory factors are checking of blood against a compatibility form away from the bedside, distraction of nursing staff during the checking process, patient identification wristbands missing, defaced or hidden under theatre drapes. The British Committee for Standards in Haematology (BCSH) guidelines on the administration of blood (which are the standards on which hospitals base their protocols for blood administration), state that it is essential that any patient having a blood transfusion must have an identification wristband in place. The National Comparative Audit of Blood Transfusion carried out in England and Wales under the auspices of the Royal College of Physicians and the National Blood Service in 2003 found that, 90% of 5014 patients were wearing wristbands during transfusion, which is encouraging. Of the 10% who were not, 52 (10% of these) were also unconscious. This is of concern, as clearly these patients would not be able to confirm their identity before blood was administered. This group of 52 constituted 1% of all patients audited and 14% of all unconscious patients. These unconscious patients were therefore at an increased risk of receiving a potentially fatal ABO incompatible blood transfusion. Should the wrong blood have been given, 12 of the 52 patients were in a side room or bay alone and would not be readily observed. In some hospitals more than 30% of patients had no wristband. Patients without wristbands most commonly belonged to paediatrics/Special Care Baby Units, oncology, ITU and haematology specialities.
Qualitative Evaluation for Safer Transfusion (QUEST) (91) aimed was to understand the pretransfusion checking process from the perspective of those who administer the blood products and to identify any common concerns with the process and suggestions to improve its safety. Twelve focus groups and seven individual interviews were conducted over a period of 22 months (May 2008 to March 2010), involving a total of 72 individuals. The participants included health care professionals from a wide variety of clinical areas. Five major areas of interest emerged from the analysis: the pretransfusion checking process, policy, training, opportunity for error, and monitoring. The pre-transfusion checking process varied between centres: four of the six sites used manual checking, one site used an automated bar-coding system, and another site used a combination of manual checking and a mechanical locking system on the blood bag. Each of the six sites had a formal hospital policy for the pretransfusion checking process. Regarding training: nursing staff, but not physicians, receive formal training in the pretransfusion checking process through one or more of the following: training at the corporate level, e-learning, and on-the-job training. Various situations were described in which the opportunity of human error could be increased, including having multiple people involved in the process and being distracted. In a busy clinical setting, multiple units of blood products may be delivered for several patients at the same time. In a busy environment, nurses may not get to spend a lot of time with any given patient and this can lead to creative ways of identifying the patient. Monitoring of transfusions generally occurred at the ward level and consisted of checking the paperwork related to the transfusions that had been administered. In summary, a number of areas for improvement were identified.