• Tiada Hasil Ditemukan

View of An Audit on Transfusion error in 16 years of blood transfusion practice at a Teaching Hospital in North Eastern Malaysia

N/A
N/A
Protected

Academic year: 2022

Share "View of An Audit on Transfusion error in 16 years of blood transfusion practice at a Teaching Hospital in North Eastern Malaysia"

Copied!
7
0
0

Tekspenuh

(1)

132

An Audit on Incorrect Blood Component Transfused at a Teaching Hospital in

North-eastern Malaysia: a single centre experience

Mohd Nazri Hassan1,2*, Noor Haslina Mohd Noor1,2, Marini Ramli1,2, Wan Suriana Wan Ab Rahman2,3, Zefarina Zulkafli1,2, Rosnah Bahar1,2, Shafini Mohamed Yusoff1,2, Salfarina Iberahim1,2,

Marne Abdullah1,2

1Department of Haematology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, 2Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, 3School of Dental Sciences, Health Campus, Universiti Sains Malaysia, 16150

Kubang Kerian, Kelantan.

*Corresponding author: nazrihas@usm.my

Received: 06 July 2022 Accepted: 25 November 2022 Published: 30 November 2022

Abstract

Clinical demand for blood transfusion is endless, and patients are exposed to the risk of transfusion error at any point along the transfusion chain which lead to incorrect blood component transfused (IBCT) if the standard transfusion practices have not complied. This study aimed to determine the prevalence, sources, and causes of error among IBCT in Hospital USM. This retrospective study involved all packed red cell (PC) transfusion and reported IBCT in Transfusion Medicine Units, Hospital USM from January 2005 to December 2020. The recipient and transfusion data of IBCT were collected from the medical record and laboratory information system (MyTransfusi). A total of 193 697 PC transfusions were documented, and 14 IBCT were reported within 16 years of transfusion services. The incidence of IBCT was 1 in 13 836 of PC transfusion. Most of the IBCT contributed by ward error (64.3%). The major cause of error was patient miss identification (85.7%) either in patient sampling, blood component issuing and administration. Most ABO incompatibility IBCT (3 out of 5) end up with severe morbidity or mortality related to an acute haemolytic transfusion reaction. Most of the errors occurred in the wards. Patient misidentification is a major cause of IBCT, and it is preventable. Thus, preventive measures should emphasize on positive patient identification at every step of transfusion chain.

Keywords

Blood transfusion, error, IBCT, Mislabeled, Patient identification.

Asian Journal of Medicine and Biomedicine

(2)

133

https://doi.org/10.37231/ajmb.2022.6.2.48 4 https://journal.unisza.edu.my/ajmb Introduction

Blood transfusion is very safe and effective when used appropriately. The process involves multiple steps starting from the decision to transfuse, prescription and request, patient blood sampling, pre-transfusion testing, collecting the component from the blood bank and finally, administration to the patient [1,2]. Several different groups are involved in the transfusion process, namely doctors, nurses, and laboratory personnel, as well as blood donors and recipients. Patients are exposed to the risk of transfusion error which lead to incorrect blood component transfused (IBCT), especially in the case of ABO-incompatible transfusion, which is capable of causing severe morbidity and mortality if any procedures in the transfusion process have deviated [3]. In the United Kingdom, the risk of IBCT is estimated at 1:15 000 blood components issue, an ABO-incompatible transfusion at 1:100 000, and the risk of death as a result of an IBCT is around 1:1 500 000 [2,4].

Transfusion error is defined as a failure to follow or any unplanned or unexpected deviation from established standard operating transfusion policies and can be categorised into IBCT and near-miss [5,6,7]. IBCT is defined when this error goes undetected and the patient’s blood components have been administered. Meanwhile, a near-miss is an error that is detected, but the blood component has not been administered yet [7]. The errors can happen at any point along the transfusion chain but particularly in the following points: 1. decision to transfuse; 2. sample errors; 3. laboratory errors; 4. blood issue; and 5.

administration errors which are considered the chain’s weakest links [2,8]. Errors that may be underreported or underestimated are an unfortunate part of transfusion services. Thus, a system in place to identify all errors occurring at any stage of the transfusion chain is required [8].

The prevention of identification checks errors regarding the patient or blood unit is essential in current transfusion practices, and it will ultimately reduce the rate of human errors and increase transfusion safety

[9]. The national performance indicator for transfusion practice in Malaysian includes zero transfusion error

[10]. To achieve this goal, analysing and identifying the causes of error in the transfusion process can further improve the safety of blood transfusion practice. These data help determine appropriate corrective and preventive actions to ensure transfusion safety. Therefore, this study aimed to determine the prevalence, source and causes of IBCT in our centre so that any corrective and preventive measures can be implemented to ensure that we are practising safe blood transfusion practices for patient safety.

Methods:

This retrospective records review involved IBCT reporting after packed red cell (PC) transfusion in Hospital USM from January 2005 until December 2020. The blood bank information system (BBIS), MyTransfusi was implemented in our transfusion service in 2010. The clinical and transfusion data of all the recipients were collected through the patient’s medical records and the BBIS. This study was approved by Human Research Ethics Committee Universiti Sains Malaysia with the protocol number USM/JEPeM/18070328.

Results:

A total of 193 697 PC transfusions were documented, and 14 cases of IBCT were reported within 16 years of practice. The prevalence of IBCT was 0.007%, with an incidence of 1 in 13 836 PC transfusions. We observed that most of the error was contributed by ward error (n=9, 64.3%), and the major cause of the error was patient miss identification (n=12, 85.7%), in which the majority occurred during sample collection (mislabelled or miscollected) and component administration to the patient (Table 1).

Most patients (n=8) had no morbidity from the IBCT since they received ABO-compatible blood, although errors had occurred. However, most patients with ABO incompatibility (3 out of 5) who were in blood group O and received a large amount of PC end up with severe morbidity or mortality related to an acute haemolytic transfusion reaction (AHTR). The only patient with RhD incompatible transfusion resulted in anti-D alloimmunization. The detail of the patient’s outcomes is summarized in Table 2.

(3)

134 Table 1: Sources and causes of the error lead to IBCT in Hospital USM from 2005 to 2020 (n=14)

Total, n (%) 2005-2009*

(5 years) 2010-2020# (11 years)

IBCT 14 8

(1.6/year) 6

(0.5/year) Source of error

Ward 9 (64.3) 4 5

Phlebotomy errors 4 4 0

Bedside administration checks 4 0 4

Administration to the wrong

recipient 1 0 1

Laboratory 5 (35.7) 3 1

Component selection error 3 3 0

Technical errors (interpretation of

blood grouping) 2 1 1

Causes of error

Patient miss identification 12 (85.7)

Sampling error 4 (28.6) 4 0

Administration error 5 (35.7) 0 5

Component issuing error 3 (21.4) 3 0

Technical error

Blood grouping error 2 (14.3) 1 1

IBCT=incorrect blood component transfused; PC=packed red cell; FFP=fresh frozen plasma; *=before implementation of blood bank information system; #= after implementation of blood bank information system

(4)

135

https://doi.org/10.37231/ajmb.2022.6.2.48 4 https://journal.unisza.edu.my/ajmb

Table 2: The details on IBCT and patient’s outcome (n=14) Patient Donor ABO/RhD

incompability

Source of error

Specific cause of error Personnel involved

Amount transfused

Patient outcome

O A Yes Ward Phlebotomy error HO 1 pint Severe AHTR with shock, death

A Yes Lab Component selection errors MLT 1 pint AHTR with DIC, survive

B Yes Ward Bedside administration checks SN <10 ml No obvious complication

AB Yes Ward Bedside administration checks SN 60 ml AHTR with ARF, survive

A B Yes Ward Phlebotomy error HO 1 pint Mild AHTR

O No Ward Phlebotomy error HO 4 pint Nil

O No Ward Phlebotomy error HO 10 ml Nil

O No Lab Component selection errors MLT 1 pint Nil

B O No Ward Bedside administration checks SN 1 pint Nil

O No Lab Incorrect ABO blood typing MLT 1 pint Nil

O No Lab Component selection errors MLT 1 pint Nil

B No Ward Bedside administration checks SN 2 pint Nil

AB B No Ward Administration to the wrong

recipient

HO, SN 1 pint Nil

A RhD – ve

A RhD +ve

Yes Lab Incorrect RhD typing MLT 1 pint Anti-D alloimmunization

HO=house officer; SN=staff nurse; MLT=medical laboratory technology; AHTR=acute haemolytic transfusion reaction; ARF=acute renal failure; DIC=disseminated intravascular coagulopathy, -ve= negative; +ve=positive; AIHA=autoimmune haemolytic anaemia

(5)

Official Journal of Faculty of Medicine, Universiti Sultan Zainal Abidin, Malaysia. 136 Discussion:

We observed that the incidence of IBCT within 16 years of transfusion practice in our centre was very low, 1 in 13 703 (0.007%). A similar study had reported the incidence of IBCT based on reports to the Serious Hazard of Transfusion (SHOT) scheme in 2003 was also very low and estimated at 1:15 000 to 16 500 [2,4]

and even lower in Berlin, 1 in 26 418 units [11]. Meanwhile, the haemovigilance report in Malaysia showed that the incidence of IBCT was less than 0.01% [11]. Although the reported IBCT is low, the true incidence might be even higher due to the failure to recognize or report the errors and the lack of complete data on transfusion events [9]. The high rate of TE indicates that the transfusion practice system is poor, and the practice needs to be reviewed and analysed to ensure all the error’s root causes have been identified and prevented.

We found that the reported source of errors (Table 1) is consistent with the previous study, where the majority were from ward errors. They reported that the most frequent error was from the ward, which was incorrect verification of patient identification (60-83%), followed by laboratory errors (11-28%) and blood issues or labelling errors (10%) [12,13,14]. Most error is due to patient misidentification during blood sampling, blood component issuing and administration. It indicates that patient identification is a critical issue in worldwide transfusion practice and at our centre. In this study, sampling error due to mislabelled and miscollected samples contributed the majority in causing the IBCT. It happens due to patient misidentification or failure in cross-checking the labels on blood specimens and patients. This failure would have the greatest effect when the wrong sample was then sent to the blood bank for blood group testing and resulted in wrong blood release from the blood bank to the ward, especially for patients with no previous record of blood group or transfusion in BBIS. Implementing BBIS can reduce the risk of human error in the blood transfusion process.

The Hospital USM implemented the computerized BBIS in 2010 to facilitate the blood transfusion request and ensure the safety of the storage, issuing and traceability of the blood and blood components. Since then, we observed that the number of reported IBCT was slightly reduced, and there were changes in the causes of IBCT. The IBCT due to sampling errors and blood issuing were eliminated since the error can be detected during pre-transfusion testing as the previous blood group record of the patient is available in the BBIS.

This error which was detected before patient being transfused was reported as near-miss event. The previous study reported that electronic documentation and information system generated specimen labels and barcoded patient verification can significantly reduce specimen related errors [15]. The institution with a computerized barcode-based blood identification system also was reported to be associated with a large increase in discovered near-miss events [16]. A recent local study on near-miss events reported that the majority of errors contributed by house officers (HO) and are due to sample mislabelled and miscollected, indicating misidentification of the patient and concluded that continuous monitoring and analysis of near- miss events is mandatory to improve transfusion safety [13].

In our centre, two main personnel directly involved in blood component transfusion process were HO and nurses. Unfortunately, after the implementation of BBIS in 2010, we observed that the administration error increased, reflecting the reduced awareness of the importance of positive patient identification at the bedside prior to the transfusion. Our recent study on the blood transfusion practice knowledge among nurses supports these findings as it showed the overall knowledge of blood transfusion among them was at a moderate level, with specifically poor levels in pre-transfusion and post-transfusion area [17]. The SHOT scheme showed that approximately 70% of errors occur in clinical areas in which the most frequently identified is a failure of the final patient identification at the bedside just prior to transfusion [4,17]. This indicates that the pre-transfusion check at the bedside is the most critical step to prevent IBCT [9]. These findings may reflect and contribute to the causes of IBCT in our centre. Based on the current and related local study findings, we have planned continuous training courses and medical education for the nurses and HO and keep on highlighting the positive patient identification in every step of the transfusion chain to improve knowledge and skills in transfusion practices.

(6)

Official Journal of Faculty of Medicine, Universiti Sultan Zainal Abidin, Malaysia. 137

https://doi.org/

https://journal.unisza.edu.my/ajmb

Regarding patient outcomes (Table 2), we observed that four out of five patients who received ABO- incompatible PC developed AHTR with variable outcomes and one patient developed RhD alloimmunisation. All of them except one received more than 50 mL of incompatible PC and developed severe morbidity and mortality from this miss transfusion. Transfusion of ABO incompatibility PC is known to cause severe and even lethal AHTR [3,14,19]. Factors that predict outcomes after ABO-incompatible PC transfusion are not well defined. Our patient outcomes are consistent with the reported findings by Janatpour et al where patients who received more than 50 mL of ABO-incompatible blood were more likely to manifest signs or symptoms of AHTR. They also observed that deaths only occurred in patients who received more than 50 mL of incompatible blood [13]. The other miss transfused patients did not exhibit any signs of a transfusion reaction since they received ABO-compatible blood or only received minimal amount of incompatible blood.

Almost all of our patients developed signs and symptoms of AHTR except in one patient who received only less than 10mL of blood. We must remember that the signs and symptoms of ABO incompatibility are not always detected or noticed. If it does, it can be nonspecific, especially in patients with coexisting morbidities. Janatpour et al. also observed that in nearly half of the cases reported, there were no associated signs or symptoms noted with the ABO-incompatible transfusion [14].

We also reported that one Rhesus D (RhD) negative patient developed RhD alloimmunisation after being transfused with RhD positive PC as patient initially was misinterpreted as RhD positive due to a miscollected sample from another patient. Hence, there was no RhD immunoglobulin prophylaxis given.

The patient is a young female and will require close monitoring when she gets pregnant in future.

Conclusions:

Although the prevalence of IBCT in our centre was relatively low, it does not indicate that our centre has good transfusion practise since maybe it is underreported. Proper reporting is vital and should be scrutinized to determine needed corrective and preventive action. The reasoning for the occurrence of error includes lack of standard operative practices nationwide, training and technology barriers. ABO incompatibility PC transfusion resulted in severe morbidity and mortality of the patient. The evidence from our study shows that the errors cannot be eliminated by just provided good facilities and equipment, guidelines, procedures and regulation, but required continuous training to increase awareness of the importance of positive patient identification and ensure that all staff understand their vulnerability and importance of good teamwork in every step of transfusion process.

Acknowledgement:

We thank the staff of the Transfusion Medicine Unit, Hospital Universiti Sains Malaysia for the support and help.

Conflict of interest:

The authors declare that there is no conflict of interest relevant to the manuscript.

References

1. Bolton-Maggs PHB, Cohen H. Seroius Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety. Br J Haematol. 2013;163(3):303-14

2. Stainsby D, Russell J, Cohen H, Lilleyman J. Reducing adverse events in blood transfusion. Br J Haematol.

2005;131(1):8-12.

3. Bolton-Maggs PHB, Watt A. Transfusion error-can they be eliminated? Br J Haematol. 2020;189(1):9- 20.

(7)

Official Journal of Faculty of Medicine, Universiti Sultan Zainal Abidin, Malaysia. 138 4. Stainsby D. ABO incompatible transfusion-experience from UK Serious Hazard of Transfusion (SHOT)

scheme transfusion ABO incompatible. Transfus Clin et Biol. 2005;12(5):385-8.

5. Nuttall GA, Stubbs JR, Oliver Jr WC. Transfusion errors: causes, incidence, and strategies for prevention.

Curr Opin Anaesthesiol. 2014;27(6):657-9.

6. Maskens C, Downie H, Wendt A, et al. Hospital-based transfusion error tracking from 2005 to 2010:

identifying the key error threatening patient transfusion safety. Transfusion. 2014;54(1):66-73.

7. Normaizira H, Izzatur Rahmi MU, Samsiah A, Nurkhairiah B, Afifah H, Siti Haniza M, et al. Blood transfusion errors: where is the critical point? Journal of Health Management. 2019;16(2):78-85.

8. Koh MBC, Alcantara R. Transfusion error and management. ISBT Sci Ser. 2009;4(2):216-20.

9. Ohsaka A. Transfusion error and their prevention. ISBT Sci Ser. 2009;4(2):390-4.

10. Ministry of Health Malaysia. Malaysian patient safety goals: guideline on implementation and surveillance. 1st edi, Published 2013. https://patientsafety.moh.gov.my/uploads/book_inside.pdf 11. Ahrens N, Pruss A, Kiesewetter H, Salama A. Failure of bedside ABO testing is still the most common

cause of incorrect blood transfusion in the barcode era. Transfus Apher Sci. 2005;33(1):25-9.

12. Pusat Darah Negara. Haemovigilance report 2018-2019: National transfusion medicine service in Malaysia. 2nd edi. Ministry of Health Malaysia. Published October, 2020.

https://www.moh.gov.my/moh/resources/Penerbitan/Laporan/Umum/HAEMOVIGILANCE_REPOR T_2018-2019_PDN.pdf

13. Mohd Noor NH, Fe Joibe K, Hassan MN. Prevalence of Near-miss Events of Transfusion Practice and Its Associated Factors amongst House Officers in a Teaching Hospital. Oman Med J. 2021;36(2):e249.

14. Janatpour KA, Kalmin ND, Jensen HM, Holland PV. Clinical Outcomes of ABO-Incompatible RBC Transfusions. Am J Clin Pathol. 2008;129(2):276-81.

15. Hill PM, Mareiniss D, Murphy P, et al. Significant reduction of laboratory specimen labeling errors by implementation of an electronic ordering system paired with a bar-code specimen labeling process.

Ann Emerg Med. 2010;56(6):630-6.

16. Nuttall GA, Abenstein JP, Stubbs JR, et al. Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors. Mayo Clin Proc. 2013;88(4):354-9.

17. Mohd Noor NH, Saad NH, Khan M, et al. Blood Transfusion Knowledge among Nurses in Malaysia: A University Hospital Experience. Int. J. Environ. Res. Public Health. 2021;18(21):11194.

18. Stainsby D, Jones H, Asher D, et al. Serious hazards of transfusion: A decade of hemovigilance in the UK.

Transfus Med Rev. 2006;20(4):273-82.

19. Tormey CA, Stack G. Delayed intravascular haemolysis following multiple asymptomatic ABO- incompatible red blood cell transfusions in a patient with hepatic failure. Vox Sanguinis.

2008;95(3):232-5.

Rujukan

DOKUMEN BERKAITAN

5.8 Pattern of ratio of plasma red cells in massive transfusion 67 5.9 Use of antifibrinolytic in bleeding major trauma patient 68 5.10 Profiles and outcomes of

On the other hand, guidelines of platelet transfusion by British Journal of Hematology recommended that platelet transfusion with identical ABO group is the best

Fear of the symptoms and effects of thalassemia treatment such as blood transfusion, chelation therapy such as dysferal and exjade were the main factors that drove

Since good awareness of blood transfusion procedure and complications among nurses could avoid transfusion error and adverse reaction as well as assuring patients’ safety,

The thalassaemia syndromes especially the transfusion dependent type are serious burden to the health services worldwide, not only because of requirement of multiple blood

characteristics in the bodies of C2, C3 and C4………..72 Figure 3.18 The six stages of cervical vertebral maturation……….75 Figure 3.19 Landmark relocation of error for upper

In both malaria-endemic and non-endemic countries, TTM can be a problem due to several characteristics of mal- aria infection: (a) partially immune individuals with low

In 2003, the Platelet Nomenclature Committee (PNC) has been created as collaboration between the International Society of Blood Transfusion (ISBT) platelet