Issue 10 - August 30, 1999
Blood Transfusion Errors: Preventing Future Occurrences
August 30, 1999

Since the Joint Commission began tracking sentinel events more than three years ago, the Accreditation Committee of the Joint Commission's Board of Commissioners has reviewed 12 cases related to transfusion errors. For each of the events reviewed, a root cause analysis was completed.

Ten of the cases resulted in patient deaths while in two of the cases the patients recovered. Also, 11 of the cases were hemolytic reactions, while one was an infectious reaction. Eleven of the transfusion reactions took place in a general hospital with eight occurring in high- risk areas: the operating room, emergency room or intensive
care unit, or during resuscitation. One of the 12 cases was in a long term care organization.

Incomplete patient/blood verifications were identified as at least one of the causes of eight of the 12 cases. Three of the 12 cases involved the handling or processing of blood samples or blood units for more than one patient at the same time in the same location. In all but one case (contaminated platelets), there were multiple failures to follow established procedures, usually involving the verification of patient identity and correct blood unit for that patient.

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"There should be blue ribbon panels set up to find optimal ways to develop a system for patient identification." James B. Battles, Ph.D., co-principal investigator, a medical event reporting system for transfusion medicine
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The Joint Commission learned of eight of the 12 cases through self-reporting. Three events were reported by state or federal regulatory agencies, and the Joint Commission learned about one case through media coverage.

Risk Factors
The processes involved in blood transfusion exhibit virtually all of the factors recognized to increase the risk of an adverse outcome:



  • Variable input (The patients have different blood types.)


  • Complexity (This includes the technical aspects of crossmatching as well as administering and monitoring the effects of blood.)


  • Inconsistency (Despite efforts to clearly define procedures within a hospital, there is no standardization across all hospitals.)


  • Tight coupling (When steps in a process happen so closely together, if there is a failure in one step there is little opportunity for intervention. It is difficult to interrupt the sequence of the process, especially in an emergency room, operating room or intensive care unit.)


  • Human intervention (This is in processes that require a higher level of consistency than is reasonably achievable by health care workers without computer support.)


  • Tight time constraints (This occurs especially in an emergency room, operating room or intensive care unit.)

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