Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses
Blood transfusions are lifesaving treatments which require critical attention to processes and details. If processes are not followed, grievous errors can lead to sentinel events. A review of investigations completed due to reported events will show the error trends associated with systems used throughout the blood transfusion process.
This study employed root cause analyses (RCAs) within the Veterans Health Administration (VHA) to review the events leading to blood transfusion errors. Data was pulled from the RCA databases within the VA National Center for Patient Safety. The time frame was October 2014 to August 2019. A total of 53 RCAs and aggregated reviews were included in the study. These were reviewed for common themes and gaps present within processes.
The most common events fell within the categories of incorrect or delayed blood orders, incorrect or lack of patient identification, and wrong blood given. The RCA for each event was reviewed and studied. The RCAs had a crossover of multiple causes; lack of a formal process, communication barriers, and technology barriers were the most frequent.
These RCAs express great variation between VHA facilities, such as process created, number of staff reports, and number of RCAs completed. Lack of standard practices nationwide, training barriers, and technology barriers may explain the variation of transfusion errors throughout the VHA. This study brings to light questions about standardization of transfusion protocols. Future study regarding such standardization is necessary to determine its plausibility.
Learoyd, P. The History of Blood Transfusion Prior to the 20th Century – Part 1. Transfus Med. 2012; 22(5):308-314.
Berseus O, et al. Risks of Hemolysis Due to Anti-A and Anti-B Caused by the Transfusion of Blood or Blood Components Containing ABO-Incompatible Plasma. Transfusion. 2013; 53:114S-123S. doi:10.1111/trf.12045, 2013.
Booth C, Allard S. Blood Transfusion. Medicine. 2017; 45(4):244-250. Doi:10.1016/j.mpmed.2017.01.014, 2017.
Singh S, Sachdev L. Transfusion Practices in a Tertiary Care Center: A Study. Int J Recent Trends Life Sci Math. 2018; 5(7):5-8.
American Cancer Society. Blood Transfusions for People with Cancer. Accessed May 15, 2020. https://www.cancer.org/treatments-and-side-effects/treatment-stypes/blood-transfu-sion-and-donation/what-are-transfusions.html.
Learoyd P. The History of Blood Transfusion Prior to the 20th Century - Part 2. Transfus Med. 2012; 22(6):372-376.
Farhud DD, Yeganeh MZ. A Brief History of Human Blood Groups. Iran J Public Health. 2013; 42(1):1-6. http://ijph.tums. ac.ir.
Red Cross. Facts About Blood and Blood Types. Accessed May 15 2020. https://www.redcrossblood.org/donate-blood-types. html.
Lambing A, Kachalsky E, Mueller ML. The Dangers of Iron Overload: Bring the Iron Police. J Am Assoc Nurse Pract. 2012; 24:175-183.
Red Cross. Blood Transfusions: Risks and Complications. Accessed May 16, 2020. https://www.redcrossblood.org/donate-blood/blood-donation-process/what-happens-to-donated-blood/blood-transfusions/risks-complications.html.
Popovsky M. Transfusion-Related Acute Lung Injury: Three Decades of Progress but Miles to Go Before We Sleep. Transfusion. 2015; 55:930-934. Doi: 10.1111/trf.13064.
Roubinian N, Murphy E. Adjusting the Focus on Transfusion-associated Circulatory Overload. Anesthesiology. 2017; 126:363-365. https://doi.org/10.1097/ALN.0000000000001507.
U.S. Food and Drug Administration. PART 606 - Current Good Manufacturing Practice for Blood and Blood Components. Sec. 606.170 Adverse reaction file. Accessed May 20, 2020. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=606.170.
Centers for Disease Control and Prevention. National Healthcare Safety Network Biovigilance Component Hemovigilance Module Surveillance Protocol. Accessed May 15, 2020. https://www.cdc.gov/nhsn/PDFs/Biovigilance/BV-HV-protocol-current.pdf.
U.S. Food and Drug Administration, Fatalities Reported to FDA Following Blood Collection and Transfusion Annual Summary for FY2018. Accessed May 20, 2020 https://www.fda. gov/media/136907/download.
Maskens C, et al. Hospital-Based Transfusion Error Tracking From 2005 to 2010: Identifying the Key Errors Threatening Patient Transfusion Safety. Transfusion. 2014; 54(1):66-73. Doi: 10.1111/trf.12240, 2014.
Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000.
Najafpour Z, et al. Preventing Blood Transfusion Failures: FMEA, an Effective Assessment Method. BMC Health Serv Res. 2017; 17(453): Doi: 10.1186/s12913-017-2380-3.
Lippi G, et al. Managing the Patient Identification Crisis in Healthcare and Laboratory Medicine. Clin Biochem. 2017; 50:562-567.
U.S. Department of Veterans Affairs. Veterans Health Administration. Published 2020. Accessed 2020. https://www.va.gov/health/#:~:text=The%20Veterans%20Health%20Administration%20is%20America’s%20largest%20integrated%20health%20care,million%20enrolled%20Veterans%20each%20year.
Bagian JP, Gosbee J, Lee CZ, et al. The Veterans Affairs Root Cause Analysis System in Action. Jt Comm J Qual Improv. 2002; 28:531–545.
Bagian JP, Lee C, Gosbee J, et al. Developing and Deploying a Patient Safety Program in a Large Health Care Delivery System: You Can’t Fix What You Don’t Know About. Jt Comm J Qual Improv. 2001; 27:522–532.
U.S. Department of Veterans Affairs. VHA National Patient Safety Improvement Handbook. Published March 04, 2011. Accessed July 12, 2020. https://www.vs.gov/vhapublications/publications.cfm?pub=2.
U.S. Department of Veterans Affairs. Pathology and Laboratry Medicine Service (PALMS) Procedures. Published January 29, 2016. Accessed February 20020. https://www.va.gov/vhapublications/publications.cfm?Pub=2.
U.S. Department of Veterans Affairs. Informed Consent for Clinical Treatments and Procedures. Published August 14, 2009. Accessed February 2020. https://www.va.gov/vhapublications/publications.cfm?Pub=2.
U.S. Department of Veterans Affairs. Transfusion Verification and Identification Requirements. June 21, 2017. Accessed February 2020. https://www.va.gov/vhapublications/publications.cfm?pub=1.
U.S. Department of Veterans Affairs. Invasive Procedures Performed in Patients Who Decline the Transfusion of Blood Products. July 7, 2014. Accessed February 2020. https://www.va.gov/vhapublications/publications.cfm?pub=1.
Department of Veterans Affairs. Enterprise Project Management Office. VistA Blood Establishment Computer Software (VBECS) Version 2.3.0: Release Notes Version 3.0. https://www.va.gov/udl/documents/Clinical/VistA_Blood_Establishment_Computer_Software/vbecs_2_3_0_release_notes.pdf.
Borgert M, et al. Implementation of a Transfusion Bundle Reduces Inappropriate Red Blood Cell Transfusions in Intensive Care - A Before and After Study. Transfus Med. 2016; 26:432-439.
Dunn E, Moga P. Patient Misidentification in Laboratory Medicine: A Qualitative Analysis of 227 Root Cause Analysis Reports in the Veterans Health Administration. Arch Pathol Lab Med. 2010; 134:244-255.
Watt A, Gyuchan T, Waterson P. Resilience in the Blood Transfusion Process: Everyday and Long-Term Adaptations to “Normal” Work. Saf Sci. 2019; 120:498-506.
Bolenius K, Brulin C, Graneheim U. Personnel’s Experiences of Phlebotomy Practices After Participating in an Educational Intervention Programme. Nurs Res Pract. 2014; 2014.
Kavaklioglu AB, Dagci S, Oren B. Determination of Health Workers’ Level of Knowledge About Blood Transfusion. North Clin Istanb. 2017; 4(2):165-172. doi:10.14744/nci.2017.41275
The Joint Commission. Sentinel Event Alert 58: Inadequate Hand-Off Communication. Published September 2017. Accessed May 2020. https://www.jointcommission.org/en/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-58-inadequate-hand-off-communication/.
Franklin CM, et al. Interprofessional Teamwork and Collaboration Between Community Health Workers and Healthcare Teams: An Integrative Review. Health Serv Res Manag Epidemiol. 2015; 2. Doi: 10.1177/2333392815573312.
Gharaveis A, Hamilton D, Pati D. The Impact of Environmental Design on Teamwork and Communication in Healthcare Facilities: A Systematic Literature Review. HERD. 2018. 11(1):119-137. Doi: 10.1177/1937586717730333.
Borgert M, et al. Timely Individual Audit and Feedback Significantly Improves Transfusion Bundle Compliance - A Comparative Study. Int J Qual Health Care. 2016; 28(5): 601-607.
Bolton-Maggs P, Wood E, Wiersum-Osselton J. Wrong Blood in Tube – Potential for Serious Outcomes: Can It be Prevented? Br J Haematol.2015; 168:3-13.
Leotsakos A, et al. Standardization in Patient Safety: The WHO High 5s Project. Int J Qual Health Care. 2014; 26(2):109-116.
National Patient Safety Foundation. Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. National Patienty Safety Foundation, Boston, MA, 2015.