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Learn how one hospital improved blood-transfusion safety

Accreditation Connection, July 16, 2004

Blood-transfusion errors are among the top 10 sentinel events that have occurred at accredited organizations since the JCAHO began reviewing sentinel events in 1995. They are also among the more complex processes in healthcare due to the many hand-offs between providers working in a variety of disciplines and departments. This complexity, coupled with the significant communication  involved in the process, makes blood transfusion an excellent target for failure modes and effects analysis.

Blood-transfusion errors are among the top 10 sentinel events that have occurred at accredited organizations since the JCAHO began reviewing sentinel events in 1995. They are also among the more complex processes in healthcare due to the many hand-offs between providers in different disciplines and departments. This complexity, coupled with the significant communication that is involved in the process, makes blood transfusion an excellent target for failure modes and effects analysis (FMEA).

The FMEA process is designed to help you identify errors before they happen. Keep in mind that the JCAHO now requires all accredited hospitals to perform an FMEA on at least one high-risk process each year.

The ultimate goal of the following FMEA is to reduce the risk of a devastating blood-transfusion error within an organization. For the this case study, a transfusion error is defined as a complication of blood transfusion where there is an immune response against the transfused blood cells or other components of the transfusion.
 
Generally speaking, healthcare organizations have built several steps into the blood-transfusion process to significantly reduce the risk of transfusion error, including

- confirming multiple patient identifiers during the various stages of the transfusion process
- typing donated blood into ABO and Rh groups prior to transfusion
- cross-matching to further confirm that the blood is compatible

Despite these universally accepted precautions, transfusion reactions continue. The immediate cause of most blood-transfusion errors occurs at the bedside-or "sharp end" of the process-where caregivers fail to detect that an incorrect unit of blood has been issued. Misidentified lab specimens are also to blame in many cases.

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