Prevention of Transfusion Complications

Many transfusion complications are preventable, especially those caused by human error. The following guidelines are central to preventing complications and minimizing their adverse effects.

• Patient/unit Identification
• Monitoring transfusion
• Education of personnel
• Quality Systems

Additional prevention strategies specific to particular complications are described with each type of adverse event.

IMMEDIATE	DELAYED
Acute hemolytic (immune) Acute hemolytic (non-immune) Febrile non-hemolytic Allergic Anaphylactic Bacterial Sepsis Transfusion-Related Acute Lung Injury (TRALI) Massive transfusion - hemostatic complications - metabolic complications - hypothermia complications Circulatory overload Air embolism Isolated hypotension	Delayed hemolytic Post-transfusion purpura Transfusion-associated GVHD Alloimmunization

Patient /unit identification

The most common cause of an acute intravascular hemolytic transfusion reaction is failure to identify the patient either during specimen collection or immediately prior to transfusion. Identification errors can lead to patients being transfused with donor blood of the wrong ABO group, resulting in life-threatening hemolysis.

This summarized excerpt from Williamson et al. is informative (Serious Hazards of Transfusion program in the UK - October 1996 to September 1998: see Further Reading):

Of 191 reported cases in which a patient was transfused with the wrong blood, 62 were ABO-incompatible transfusions, leading to three deaths. The errors in 177 analysed cases generally consisted of a sequence of one to seven failures to detect incorrect identity of donor blood or patient.

First errors occurred at all stages:

• during the request for blood or sampling of the patient, or both (33) in the transfusion laboratory (59)
• when collecting blood from the blood bank refrigerator, which was the major source of primary error (61)
• at the bedside check prior to transfusion, despite being carried out by two people (80). In 20 incidents, the patient had no identity wrist band.

The 2000-2001 SHOT Report is also available (118 page-PDF doc).

Note: Canadian Blood Services offers no endorsement of and assumes no liability for the currency, accuracy, or availability of any information on these sites.

Key findings include:

• The largest category (213/315 reports) remains transfusion of the wrong blood.
• Cumulative data over five years show that the largest category of reports is blood transfusion errors with the wrong blood transfused to patients accounting for 61% (699/1148) of cases.
  - The outcome of these was death in 11 patients (five definitely related to transfusion, one probably, and five possibly related) and major morbidity, e.g., conditions necessitating ICU admission in 60 cases as a result of ABO and/or other red cell incompatibility.
• As in previous years, multiple errors were implicated in many wrong blood incidents.

These and other reports show that the single most important key to prevention is a system of proper identification protocols at each stage where identification errors may occur:

• drawing the recipient's crossmatch specimen
• labelling the recipient's blood specimen (to avoid errors must be done in the presence of the patient)
• performing pretransfusion testing in the transfusion service
• issuing the blood unit from the transfusion service
• identifying patient and unit immediately prior to transfusion so that the correct donor blood is transfused

Patient monitoring during transfusion

Patient surveillance during the administration of blood and blood products is a critical element of blood safety. Because the severity of a reaction is often correlated to the volume transfused, patients should be monitored during transfusion as follows:

• vital signs immediately before beginning the transfusion during the first 15 minutes of transfusion, a nurse should remain with the patient
• periodic patient observation, including monitoring of vital signs during the transfusion

Education of all personnel involved in transfusion

Besides primary professional education, all health professionals involved in transfusion require continuing education and updating in this rapidly evolving field. Informed and conscientious staff are critical to patient safety. Strategies include transfusion education spearheaded by:

• transfusion committees
• transfusion safety officers
• blood conservation officers

Having a quality system in place is also key. A quality system with defined personnel training and competency assessment, internal audits, and error management policies provide an increased likelihood that transfusion service operations are properly controlled and functioning safely.

Lumadue and coworkers (see Further Reading) reported that specimens that failed to meet the criteria for specimen acceptance at their institution were 40 times more likely to have a blood grouping discrepancy when compared with historic or subsequent patient data.