September 2018

Positive Patient Identification and Independent Double Checks: Why are these important in transfusion safety?

By: Bev Weaver, TSO, Senior MLT, Kingston Health Sciences Centre

The administration of blood and blood components and the management of the transfused patient are complex and multi-step processes with various opportunities for errors to occur. The Serious Hazards of Transfusion (SHOT-UK Hemovigilance System) reports1 demonstrate that cases of incorrect transfusion often result from a sequence of errors involving failure to detect the correct identity of the patient and/or the blood component.

 

The safe administration of blood components and products requires that the health care professional and Blood Bank personnel work together to meet the patient’s needs. Systematic policy and procedural guidelines are emphasized to maximize patient safety during transfusions.

 

Positive patient identification is a crucial component of transfusion safety. If patient identification is incorrect it can have potentially fatal consequences. An acute adverse reaction can be caused by transfusing 3 mls of the wrong blood.2

 

You must accurately identify the patient at the bedside when collecting a blood sample to ensure that the sample has been drawn on the correct patient and that the sample tubes are labeled accurately. This must occur before leaving the patient’s bedside. Protect your patient and yourself: only label samples that you have drawn from the patient.

 

Ask the patient for their first and last name and their date of birth if they are able to verbally respond. Always check that the patient’s name, date of birth and unique identifier (usually a hospital registration number) on the armband matches with the orders and labels. Some hospitals have incorporated new positive patient identification technology as the new standard for safety. A computerized system uses a barcode, radio frequency identification (RFID), or another electronically readable component contained in a patient’s armband to confirm identity. In the context of transfusion safety, the armband is scanned prior to sample draws and prior to any transfusions.

 

Mistakes happen even when people are doing their best. According to publicized data about blood administration, the general rate of errors of commission is 3 in 1000, the general rate of errors of omission when no reminders exist is 1 in 100, and the general error rate in a highly stressed environment with rapidly occurring activities is 1 in 4.3

 

The institute for Safe Medication Practices Canada (ISMP Canada) recommends conducting independent double checks with selected high-risk processes and high-alert drugs.4 Independent double checks are not intended to question the practitioners’ skills or competence; rather, they acknowledge the high-risk nature or complexity of the work and the fact that all practitioners are only human and therefore fallible. Many Canadian hospitals have implemented independent double check processes in an effort to enhance patient safety.

 

Before beginning the transfusion, two practitioners independently check the following information in the presence of the intended recipient:

  • If the patient is capable, they are positively identified by asking them to state their surname, first name, and date of birth.
  • The patient’s surname, first name and unique number on the blood component are identical to the patient’s identification bracelet.
  • Donor unit identification – The donor unit identification number on the hospital transfusion label attached to one side of the blood bag agrees with the Canadian Blood Services label attached to the other side of the blood bag.
  • The ABO and Rh type on the hospital transfusion label attached to the one side of the blood pack agrees with the Canadian Blood Services label attached to the other side of the blood bag.
  • When performed, the compatibility test result on the transfusion label attached to one side of the blood pack is verified to be ‘compatible’.
  • Any discrepancies found during the independent double check must be addressed before beginning the transfusion.
  • Notify the Blood Bank about any unresolved discrepancies and return the blood bag to the lab if so advised.

The greatest transfusion risk to patients occurs at the bedside; from obtaining a blood sample to transfusing a product. The number one cause of an acute hemolytic transfusion reaction is failure to check the patient armband. Imbedding positive patient identification and independent double checks in transfusion practices will enhance patient safety.

 

References:

  1. https://www.shotuk.org/shot-reports/
  2. Society for Advancement of Blood Management (SABM). Blood Administration Safety. 2015.
  3. Institute for Safe Medication Practices Canada (2005). Lowering the risk of Medication Errors: independent double checks. 5(1).
  4. Institute for Safe Medication Practices Canada (2005). Lowering the risk of Medication Errors: independent double checks. 5(1).

 

Provincial Bedside Audit

By: Tracy Cameron, Regional Project Coordinator, NE ORBCoN

ORBCoN is conducting a 2018 Provincial Bedside Audit which commenced on Tuesday September 4th, 2018 and will end on Friday November 30th, 2018. All hospitals in Ontario have been invited to participate, and a communication was sent out in early July with a reminder communication sent out in August.

 

Similar to the previous provincial audit, there will be a paper audit form provided to perform the audit at the bedside and a web based audit tool to facilitate the data entry of the audit results. Hospitals will be able to review their own data, and provincial data will be summarised and shared in a report. In the previous provincial audit, most Research Ethics Board (REB) committees considered this type of audit to be a quality improvement initiative and did not require full ethics review, but be sure to check with your committee if you have concerns.
The number of audits to be performed will be based on your hospital’s classification.

 

Hospital Classification # of transfusion procedures/duration
Small Community 2 transfusion procedures or 3 months
Medium to Large Community 5 transfusion procedures or 3 months
Teaching 10 transfusion procedures or 3 months

The 2011 Provincial Bedside Audit had a total of 80 (51%) hospitals in the province participating and captured 359 transfusion procedures. The highest compliance with standards was seen in the category of patient identification. The lowest compliance was seen in the category of “order confirmation check”. The goal of the 2018 audit is to collect the data and compare the results with those from the previous audit to see if there have been improvements in compliance with current standards1,2 and critical steps in the process of blood administration. If you have any questions about this audit please contact us at info@transfusionontario.org

 

References:

  1. CSA Z902-15 Canadian Standards Association Standards for Blood and Blood Components December 2015; CSA Group
  2. Canadian Society for Transfusion Medicine Standards for Hospital Transfusion Services; v4 April 2017; CSTM

 

 

 

When should a blood infusion set be changed during a blood transfusion?
By: Leonor De Biasio, Clinical Project Coordinator, Transfusion Safety Nurse, CE ORBCoN

 

One of the key elements of administering blood components to patients is optimal safety of the blood transfusion. Optimal safety is comprised of several components and one is avoidance of any adverse transfusion reactions, which include transmission of infectious microorganisms. One recommended method to ensure minimizing bacterial growth or contamination is to replace the blood administration set at the most appropriate time during the administration process, especially if transfusing more than one unit. Consequently, the question arises “When should a blood infusion set be changed during the blood transfusion?”

 

Several organizations specializing in transfusion medicine have developed and published recommendations and/or standards for the appropriate time to replace infusion sets. It has been noted by health care professionals that the recommendations or standards published by these organizations vary from one another. Because of these diverse recommendations or standards available, these have posed a slight challenge to some health care professionals as to which recommendation or standard should be exercised in their practice. Below are excerpts of just a few of the recommendations and standards that are published.

 

2014 AABB Technical Manual 18th Edition pg 555
If additional units are transfused the hospital’s guidelines and manufacturer’s recommendation should be consulted to determine whether the same blood administration tubing may be used for subsequent units. If there are no contraindications from the manufacturer, institutions frequently allow tubing to be reused as long as subsequent units are transfused within 4 hours of the start of the initial transfusion. Therefore, if more than 1 unit can be infused in 4 hours, blood administration tubing sets may be used for more than one component.

 

BEBA Version 2 pg. 19
Blood tubing must be changed at least every 2-4 units and within the number of hours specified by your hospital policy. In cases of massive transfusion, an add-on filter can be used to minimize the frequency of tubing changes.

 

2015 CSA Z902-15 Blood and Blood Components 11.4.13
Administration sets shall be changed at least once every 24 h. Standard blood administration sets shall be changed after 4 units of red blood cells or if the set becomes occluded. Add-on filters and specialized blood sets (e.g., rapid infuser sets) shall be changed at intervals as recommended by the manufacturer or in accordance with hospital policy.

 

2017 CSTM Standards for Hospital Transfusion Services Version 4 5.9.4.7
Administration sets shall be changed according to set or filter manufacturer’s recommendations or at least once every 24 hours or after 4 units of red cells. The administration set shall be changed immediately prior to the transfusion of platelets.

 

Infusion Nurses Society: 2016 Infusion Therapy Standards of Practice p.136
Change the transfusion administration set and filter after the completion of each unit or every 4 hours. If more than 1 unit can be infused in 4 hours, the transfusion set can be used for a 4-hour period (see Standard 42, Administration Set Change).

 

Infusion Nurses Society: Policy and Procedure for Infusion Therapy Fifth Edition p.225
The administration set is changed after the completion of each unit or every 4 hours; if more than 1 unit can be infused in 4 hours, the transfusion set can be used for a 4-hour period.

 


So, why the discrepancy? In 2008, Transfusion Medicine published a study by Blest et al., which suggested the reason for the variety in recommendations from 4 hours to 48 hours and from one unit to several units was a result of no formal evidence base on which to support or challenge current recommendations. Blest et al. concluded that further research is warranted and would need to include variables that impact frequency of change, including type of filter, age of blood and duration of blood component transfusion.


To our knowledge, there have not been any reports in Ontario of any adverse transfusion reactions attributed to bacterial contamination from blood infusion sets. Therefore, it is recommended that health care professionals involved in administration of blood follow blood administration standards and their institution’s policy and procedures for blood administration and replacement of blood infusion sets.