Error in hospital transfusion process and mitigation measures: Scoping Review
DOI:
https://doi.org/10.25746/ruiips.v11.i1.29906Keywords:
errors, near miss, blood transfusion, mitigation measures.Abstract
The transfusion of blood, components and derivatives is an essential therapy in many treatments to resolve clinical situations that would be irreversible without its administration. However, like all medical acts, adverse effects may occur, some of them caused by human error. In Portugal, the National Hemovigilance System makes these human errors public through its annual report. The objectives of this review are to verify whether there is consistency between the errors and near-misses detected in the hospital transfusion process in Portugal and those published in papers from different countries, and what measures should be implemented to mitigate these errors. This is a systematic scoping review. For this purpose, a literature search was performed and was carried out using PubMed, SciELO and Mendely databases only with the filter of publication date (last 5 years). MeSH (Medical Subject Headings) Terms and the appropriate keywords were used in the search strategy - For this analysis 23 studies that met all inclusion criteria were considered. The results were evaluated according to the pre-analytical, analytical and post-analytical phases. The errors identified were mostly in the pre- and post-analytical phases: with great emphasis on errors in patient identification; either when collecting and labeling the pre-transfusion sample, or prior to the administration of the blood component; and are consistent with the results found in Portugal. The recommended error mitigation measures are of various types and range from specific training of all professionals involved in the transfusion chain to the use of dedicated computer systems, through various recommendations and always aiming at reducing human intervention. We conclude that the cause and type of errors coincide with those recorded in Portugal and that, despite efforts to mitigate errors in the transfusion process, they still occur, although many are detected prior to transfusion (near misses). The knowledge of these types of detected errors allows risk assessment and the implementation of measures that may be more effective in preventing them.
References
Amendoeira, J., Silva, M., Ferrira, M., Dias, H., (2022). Tutorial revisão sistemática de literatura: a scoping review. UMIS_UI_IPSantarém | Centro de Investigação em Qualidade de Vida. Instituto Politécnico de Santarém UMIS-ESSS. http://hdl.handle.net/10400.15/3784
Bolton-Maggs, P. H., & Watt, A. (2020). Transfusion errors - can they be eliminat-ed? British Journal of Haematology, 2020; Nº189 (pp. 9–20). DOI: 10.1111/bjh.16256. PubMed. https://pubmed.ncbi.nlm.nih.gov/31792932/
Centre UM, (2013). Glossary of terms used in Pharmacovigilance (GTUP), 2013. Disponível em https://globalpharmacovigilance.tghn.org/resources/glossary/
Chou, S. S., Chen, Y. J., Shen, Y. T., Yen, H. F., & Kuo, S. C. (2019). Implementation and Effectiveness of a Bar Code-Based Transfusion Management System for Transfusion Safety in a Tertiary Hospital: Retrospective Quality Improvement Study. JMIR medical informatics, 7(3), e14192. https://doi.org/10.2196/14192
Creswell, J. W. (2009). Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. In SAGE Publications, Inc (3rd ed.). SAGE. https://doi.org/10.1080/14675980902922143
Decreto-lei n. º 267/2007. (2007). Regime jurídico da qualidade e segurança do sangue humano e dos componentes sanguíneos, respetivas exigências técnicas, requisitos de rastreabilidade e notificação de reações e incidentes adversos graves e as noras e especificações relativas ao Sangue. Diário da República n. º 141/2007, Série I, n. º 141 de 2007-07-24. DRE. https://dre.pt/dre/legislacao-consolidada/decreto-lei/2007-107758159
Dunbar, N. M., Delaney, M., Murphy, M. F., Pagano, M. B., Saifee, N. H., Seheult, J., Yazer, M., Kaufman, R. M., & WBIT Study Investigators on behalf of the Biomedical Excellence for Safer Transfusion (BEST) Collaborative (2021). Emergency departments are higher-risk locations for wrong blood in tube errors. Transfusion, 61(9), 2601–2610. https://doi.org/10.1111/trf.16588
Elliot, J., Narayan, S., Poles, D., Tuckley, V., & Bolton-Maggs, P. H. B. (2021). Missed irradiation of cellular blood components for vulnerable patients: Insights from 10 years of SHOT data. Transfusion, 61(2), 385–392. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7894557/
Encan, B., & Akin, S. (2019). Knowledge of Blood Transfusion Among Nurses. Journal of continuing education in nursing, 50(4), 176–182. https://doi.org/10.3928/0022012420190319-08
Manual para Uso Ótimo do Sangue. (2010). 20776-07 Portuguese Optimal Blood Use. Hemovigilância. PDF. http://www.hemovigilancia.net/docs/portuguese_blood_use_manual.pdf
Faria, G. N., Zilotti, L. T., & Andrade, R. J. (2021). The most common inadequacies in red blood cell requests at a reference center in Western Paraná state. Hematology, transfusion and cell therapy, S2531-1379(21)01306-7. Advance online publication. https://doi.org/10.1016/j.htct.2021.07.011
Faria, J. C. P., Cansian, B., Arruda, É. E. C., Victorino, C. A., & Szulman, A. (2020). Prescription of red cell concentrates by emergency physicians. Revista da Associação Medica Brasileira (1992), 66(4), 466–471. https://doi.org/10.1590/1806-9282.66.4.466
Fragata, J., Santos, S., Ferreira, S., Barros, P. P., Bilbao, M., Fragata, I., & França, M. (2006). Risco clínico: complexidade e performance. Edições Almedina. ISBN: 9724028356
Garcia, J., Silva, S. S., Meneguci, J., & Moraes-Souza, H. (2022). Profile of hemotherapy care and the safety of the transfusion process. Revista da Associação Medica Brasileira (1992), 68(6), 770–774. https://doi.org/10.1590/1806-9282.20211246
Glisch, C., Jawa, Z., Brener, A., Carpenter, E., Gottschall, J., Treml, A., & Karafin, M. S. (2018). Evaluation of a two-sample process for prevention of ABO mistransfusions in a high-volume academic hospital. BMJ open quality, 7(3), e000270. https://doi.org/10.1136/bmjoq-2017-000270
Hensley, N. B., Koch, C. G., Pronovost, P. J., Mershon, B. H., Boyd, J., Franklin, S., Moore, D., Sheridan, K., Steele, A., & Stierer, T. L. (2019). Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative Blood Component Administration. Joint Commission journal on quality and patient safety, 45(3), 190–198. https://doi.org/10.1016/j.jcjq.2018.08.010
IPST, IP: Instituto Português do Sangue e da Transplantação. (2011). Definições padronizadas para a vigilância de reações transfusionais não infeciosas - Reações Adversas. Hemovigilância. http://www.hemovigilancia.net/files/Portuguese_ISBT_definitions_jul_2011_verso_01.pdf
ISBT: International Society of Blood Transfusion. (2020). Introduction to Blood Transfusion: from donor to recipient | The International Society of Blood Transfusion (ISBT). ISBT Science Series, Volume 15, Sup. 1. dezembro 2020. https://www.isbtweb.org/resources/publications/beryl-s-book.html
Kaufman, R. M., Dinh, A., Cohn, C. S., Fung, M. K., Gorlin, J., Melanson, S., Murphy, M. F., Ziman, A., Elahie, A. L., Chasse, D., Degree, L., Dunbar, N. M., Dzik, W. H., Flanagan, P., Gabert, K., Ipe, T. S., Jackson, B., Lane, D., Raspollini, E., Ray, C., BEST Collaborative (2019). Electronic patient identification for sample labeling reduces wrong blood in tube errors. Transfusion, 59(3), 972–980. https://doi.org/10.1111/trf.15102
Khetan, D., Katharia, R., Pandey, H. C., Chaudhary, R., Harsvardhan, R., Pandey, H., & Sonkar, A. (2018). Assessment of bedside transfusion practices at a tertiary care center: A step closer to controlling the chaos. Asian journal of transfusion science, 12(1), 27–33. https://doi.org/10.4103/ajts.AJTS_29_17
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P. A., Clarke, M., Devereaux, P. J., Kleijnen, J., & Moher, D. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ (Clinical Research Ed.), 339. https://doi.org/10.1136/bmj.b2700
Mistry, H., Poles, D., Watt, A., Bolton-Maggs, P. H. B., & SHOT Steering Group (2019). Human errors in manual techniques for ABO/D grouping are associated with potentially lethal outcomes. Transfusion medicine (Oxford, England), 29(4), 262–267. https://doi.org/10.1111/tme.12616
Mora, A., Ayala, L., Bielza, R., Ataúlfo González, F., & Villegas, A. (2019). Improving safety in blood transfusion using failure mode and effect analysis. Transfusion, 59(2), 516–523. https://doi.org/10.1111/trf.15137
Murphy, M. F., Jayne Addison, J., Poles, D., Dhiman, P., & Bolton-Maggs, P. (2019). Electronic identification systems reduce the number of wrong components transfused. Transfusion, 59(12), 3601–3607. https://doi.org/10.1111/trf.15537
Nascimento, F., (2011). Haemovigilance: a tool for quality improvement. ISBT Science Series, 6(1), 84–88. https://doi.org/10.1111/j.1751-2824.2011.01443.x
Noor, N. H. M., Joibe, K. F., & Hasan, M. N. (2021). Prevalence of Near-miss Events of Transfusion Practice and Its Associated Factors amongst House Officers in a Teaching Hospital. Oman medical journal, 36(2), e249. https://pubmed.ncbi.nlm.nih.gov/33898061/
Norma 015/2013 atualizada em 2015. (2015). Direção-Geral de Saúde - Consentimento Informado, Esclarecido e Livre Dado por Escrito para atos/intervenções de saúde nos termos da norma nº 015/2013. DGS. Acedido janeiro 22, 2023, em http://www.aenfermagemeasleis.pt/wp/wp-content/uploads/2015/11/Norma-015-DGS-Consentimento-informado-esclarecido-e-livre-dado-por-escrito-04-11-20151.pdf
Obaidallah, N., Downie, H., Colavecchia, C., Callum, J., & Lin, Y. (2022). Implementation of a blood bank generated tube for second blood group determination: Challenges, yield, and cost. Transfusion, 62(4), 784–790. https://doi.org/10.1111/trf.16838
RA:2021: Relatório de Atividade Transfusional e Sistema Português de Hemovigilância 2021 (2022). IPST, IP https://ipst.pt/files/RA_2021.pdf
Ri, M., Kasai, M., Kohno, A., Kondo, M., Sawa, M., Kinoshita, T., Sugiura, I., Miura, Y., Yamamoto, K., Saito, T. I., Ozawa, Y., Matsushita, T., & Kato, H. (2020). A survey of blood transfusion errors in Aichi Prefecture in Japan: Identifying major lapses threatening the safety of transfusion recipients. Transfusion and apheresis science: official journal of the World Apheresis Association: official journal of the European Society for Haemapheresis, 59(3), 102735. https://doi.org/10.1016/j.transci.2020.102735
Roudsari, D., Feizi, S., Maghsudlu, M. (2021). Nurses’ hemovigilance knowledge and performance after teach-back, concept map, and lecture: A quasi-experimental study. Heliyon 7 (2021). https://doi.org/10.1016/j.heliyon.2021.e05982
Sawadogo, S., Nebie, K., Millogo, T., Sontie, S., Nana, A., Dahourou, H., Yonli, D. Y., Tapko, J. B., Faber, J. C., Kafando, E., & Deneys, V. (2018). Traceability of Blood Transfusions and Reporting of Adverse Reactions in Developing Countries: A Six-Year Postpilot Phase Experience in Burkina Faso. Advances in hematology, 2018, 7938130. https://doi.org/10.1155/2018/7938130
Sinha, R. (2022). Wrong Number On Tube. International Journal of Innovative Research and Advanced Studies (IJIRAS) Volume 9 Issue 12, (pp. 58-59), December 2022. Disponível em https://www.ijiras.com/2022/Vol_9-Issue_12/paper_7.pdf
Spronk, A., de Jong, R., Koopman, S., Hoeks, S., & Jan Stolker, R. (2021). Blood transfusion decisions cannot be based on percutaneous haemoglobin measurements. Anaesthesiology intensive therapy, 53(2), 103–107. https://doi.org/10.5114/ait.2021.105658
Storch, E. K., Rogerson, B., & Eder, A. F. (2020). Trend in ABO-incompatible RBC transfusion-related fatalities reported to the FDA, 2000-2019. Transfusion, 60(12), 2867–2875. https://doi.org/10.1111/trf.16121
Tang, Y. L., Yousuf, R., Wan Nawawi, W. M., Rahman, I. L., Zainal Abidin, J., Rechard Nathan, V. R., & Leong, C. F. (2019). An Audit on Overnight Transfusion Practice in A Teaching Hospital in Malaysia. The Malaysian journal of pathology, 41(2), 161–167. https://pubmed.ncbi.nlm.nih.gov/31427551/
Vijenthira, S., Armali, C., Downie, H., Wilson, A., Paton, K., Berry, B., Cserti-Gazdewich, C., Callum, J. (2019) Registration Errors Among Patients Receiving Blood Transfusions: A National Analysis from 2008-2017. Blood 2019; 134 (Supplement_1): 3689. https://doi.org/10.1182/blood-2019-130615
Vilelas, J. (202). Investigação. O processo de construção do conhecimento (3.ªed.). Edições Sílabo, Lda. ISBN: 978-989-561-097-6.
WHO - World Health Organization. (2009). Conceptual framework for the international classification for patient safety version 1.1: final technical report. Genova: World Health Organization (WHO). Disponível em https://apps.who.int/iris/handle/10665/70882
Wood, E. M., Ang, A. L., Bisht, A., Bolton-Maggs, P. H., Bokhorst, A. G., Flesland, O., Land, K., Wiersum-Osselton, J. C., Schipperus, M. R., Tiberghien, P., & Whitaker, B. I. (2019). International haemovigilance: what have we learned and what do we need to do next? Transfusion medicine (Oxford, England), 29(4), 221–230. https://doi.org/10.1111/tme.12582
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