SHOT Annual Report 2009 - Serious Hazards of Transfusion

Case 1
Incorrect DOB on documentation not detected during competency-assessment
A doctor took a transfusion sample from a patient without a wristband and did not positively identify the patient, asking
only the name. A labelled sample and a request form had the incorrect DOB, copied from admission documentation.
The DOB error was not noted during pre-transfusion checks and the first unit was transfused. The nurses performing
the bedside check were being assessed for competency during this procedure; they were passed as competent. The
incorrect DOB was noted during checks of the second unit.
This case highlights the risk of failing to undertake a formal patient ID check prior to taking the blood sample, and how
even when staff are being observed errors can still occur.
Case 2
Incorrect hospital number – detected but ignored
An FY1 doctor entered another patient’s hospital number on a blood sample for a patient requiring a blood transfusion.
As a result 4 units of blood were issued to this patient. When the nurses questioned the different number on the
patient’s wristband with the FY1, she requested them to ignore this because the patient urgently needed the blood.
The patient’s Hb was 6.2 g/dL. The nurses proceeded to give all 4 units of blood based on another patient’s hospital
number.
This case highlights the importance of checking patient details when completing the request form and sample tube and
the importance of taking corrective action when risks or errors are identified.
Case 3
Transposition of barcoded labels on units for the same patient
Because the transfusion laboratory printer failed, a BMS handwrote issue reports and traceability labels, by mistake
transposing the ISBT numbers on the peel-off sections of 2 units and writing 1 incorrect digit in the hospital number.
The transposition of the barcode and the incorrect hospital number were noticed by ward staff before transfusion. The
label was returned to the laboratory to be amended. The BMS had been under pressure to issue the blood: the porter
was waiting, and had informed the BMS that the patient had collapsed.
This case emphasises the need for staff to be extra vigilant when errors occur in IT/electronic systems, even in emergency
situations.
Case 4
Longstanding use of variations in patient’s first name
The transfusion laboratory was contacted because the paperwork for the blood transfusion of a patient had an incorrect
forename. The error was noticed on the ward while checking the second unit of blood. The sample and request form
were correct, but the duty BMS did not notice the discrepancy with laboratory records. The sample was processed and
blood issued (electronic issue): again the discrepant name was not picked up on issuing or labelling the blood. On
investigation, there were multiple pathology requests for this patient with this discrepancy. On 1 request, the incorrect
name had been used on the request form, so the name was changed. On other subsequent requests, the correct name
was on the request, but the computer system was not updated. On one of these, a comment was put on that the
forename on the sample was inaccurate.
This case stresses the importance of checking the patient details when inputting patient data on electronic systems and
taking remedial action when a discrepancy is identified.
64 7.2 Right Blood Right Patient (RBRP)