The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Tan GM, Murto K, Downey LA, et al. Paediatr Anaesth. 2023;33:609-619.
Blood management errors can lead to serious patient harm. This article highlights five patient safety risks during pediatric perioperative blood management (failure to recognize and treat preoperative anemia, failure to obtain informed consent regarding perioperative blood management, failure to consider specific intraoperative blood conservation techniques in children, failure to recognize massive hemorrhage, failure to prevent unnecessary transfusion). The authors discuss potential solutions to address these safety risks.
S Narayan, ed. Manchester, UK: Serious Hazards of Transfusion (SHOT) Steering Group; 2023. ISBN: 9781999596859.
Although errors in the blood transfusion process are rare, they can be harmful. This annual report provides an analysis of transfusion-related errors reported to a national improvement program in the United Kingdom. The 2022 report recommends enhancing focus on underreporting and emergency department report activity as targets for study. Previous reports in the series are available.
Incorrect patient registration, application of the wrong label, and blood draw from the wrong patient can all cause blood transfusion errors. This systematic review identified six studies related to nursing and blood transfusion safety. Errors fell into two broad categories - human and environmental factors, and education. Initial and continuing education for all members of the team, including registration staff, should be considered to improve and maintain transfusion safety.
Jadwin DF, Fenderson PG, Friedman MT, et al. Jt Comm J Qual Patient Saf. 2023;49:42-52.
Blood transfusions errors can have serious consequences. In this retrospective study including 15 community hospitals, researchers identified high rates of unnecessary blood transfusions, primarily attributed to overreliance on laboratory transfusion criteria and failure to follow guidelines regarding blood management.
Uramatsu M, Maeda H, Mishima S, et al. J Cardiothorac Surg. 2022;17:182.
Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.
Wrong blood in tube (WBIT) errors can be classified as intended patient drawn/wrong label applied or wrong patient/intended label applied. In this international study, errors were divided almost evenly between the two types and most were a combination of protocol violations (e.g. technology not used or not used appropriately) and slips/lapses (e.g., registration errors). Additional contributory factors and recommendations for improvement are also discussed.
Duzyj CM, Boyle C, Mahoney K, et al. Am J Perinatol. 2021;38:1281-1288.
Pregnancy and childbirth are recognized as high-risk activities for both the pregnant person and infant. This article describes the implementation of a postpartum hemorrhage patient safety bundle. Successes, challenges and recommendations for implementation are included.
Dunbar NM, Delaney M, Murphy MF, et al. Transfusion (Paris). 2021;61:2601-2610.
Transfusion errors can have serious consequences. This study compared wrong blood in tube (WBIT) errors in 9 countries across three settings: emergency department, inpatient, and outpatient. Results show emergency department WBIT errors were significantly higher in emergency departments, and that electronic positive patient identification (ePPID) significantly reduced WBIT errors in the emergency department, but not in inpatient or outpatient wards.
Safety in home health care delivery is receiving increasing attention. This retrospective cohort study found that patients with medically stable, chronic conditions undergoing blood transfusion in a home setting provided by a nurse-led service experienced low rates of adverse events.
Transfusion errors can have serious consequences. This retrospective analysis used a Canadian national database to characterize patient registration-related errors in the blood transfusion process. Findings indicate that registration errors most commonly occur in outpatient areas and emergency departments and can lead to delays in transfusion.
Vanneman MW, Balakrishna A, Lang AL, et al. Anesth Analg. 2020;131:1217-1227.
Transfusion errors due to patient misidentification can have serious consequences. This article describes the implementation of an automated, electronic barcode scanner system to improve pretransfusion verification and documentation. Over two years, the system improved documentation compliance and averted transfusion of mismatched blood products in 20 patients.
A 74-year-old male with a history of hypertension, hyperlipidemia, paroxysmal atrial fibrillation, coronary artery disease, congestive heart failure with an EF of 45%, stage I chronic kidney disease and gout presented for a total hip replacement.
This analysis of transfusion-related safety incident reports found that such events were more commonly reported for pediatric compared to adult patients. This finding could reflect differences in reporting practices or underlying transfusion safety differences. The authors call for continued attention to transfusion safety.
First admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding, a woman (G5 P2 A2) received 4 units of packed red blood cells and 2 doses of iron injections. She was discharged after 3 days with an improved hemoglobin level. At 35 weeks, she was admitted for an elective cesarean delivery. Intraoperatively, an upper uterine segment incision was made and the newborn was delivered in good condition. Immediately after, a subtotal hysterectomy was performed. The anesthesiologist noted that the patient was hypotensive; blood was transfused.
Kaufman RM, Dinh A, Cohn CS, et al. Transfusion (Paris). 2019;59:972-980.
Wrong-patient errors in blood transfusion can lead to serious patient harm. Research has shown that use of barcodes to ensure correct patient identification can reduce medication errors, but less is known about barcoding in transfusion management. This pre–post study examined the impact of barcode labeling on the rate of wrong blood in tube errors. Investigators found that use of barcoding improved the accuracy of labels on blood samples and samples that had even minor labeling errors had an increased chance of misidentifying the patient. The authors conclude that the results support the use of barcoding and the exclusion of blood samples with even minor labeling errors in order to ensure safe blood transfusion. An accompanying editorial delineates the complex workflow, hardware, and software required to implement barcoding for transfusion. A past WebM&M commentary discussed an incident involving a mislabeled blood specimen.
Cohen R, Ning S, Yan MTS, et al. Transfus Med Rev. 2019;33:78-83.
Inaccurate patient registration can result in information gaps that contribute to delay, misunderstandings, and harm. This review discusses registration errors in the blood transfusion process. The authors discuss how problems can occur during various stages in the transfusion process and result in blood-type discrepancies. They suggest improved reporting of identification mistakes and use of photo identification tools as strategies to prevent patient harm associated with registration errors.
MacDougall N, Dong F, Broussard L, et al. Anesth Analg. 2018;126:247-251.
Transfusion of incompatible blood products can cause severe patient harm and is considered a never event. Based on findings in this study, researchers suggest that use of a blood product compatibility cognitive aid may improve transfusion safety.
Najafpour Z, Hasoumi M, Behzadi F, et al. BMC Health Serv Res. 2017;17:453.
Failure mode and effect analysis (FMEA) is a tool that facilitates prospective risk assessment and is frequently used to assess the risk of various processes in health care. The authors describe the use of FMEA at a single institution to improve the safety of the blood transfusion process.
An older man with Crohn disease was admitted for abdominal pain and high stool output from his ileostomy. Despite blood passing from his ostomy and a falling hemoglobin level, the patient was not given a timely blood transfusion.