Blood Bank Errors

Blood bank procedures are highly regimented; however, the procedures are effective only if they are followed. There are many steps in the procedures with the potential for an inappropriate action. One such step is testing. Blood bank testing errors account for about 15% of transfusion errors (Linden et al., 2000; Sazama, 1990). Testing presents many opportunities for error. In typing the sample, a blood bank staffer could take the wrong patient's sample from the test tube rack and use it for testing. In testing the sample, the typing chemicals could be added in the wrong order or not at all, so that a visible reaction would not occur. The reactions might not be interpreted correctly, giving rise to an incorrect determination of compatibility. There also is the opportunity for a clerical error, such as recording the results for one patient in the box on the results form designated for another patient. In Sam's case, Laura Peterson performed the testing correctly.

Blood bank errors also can occur at the point of releasing a unit of blood for transfusion. A common error is when blood removed from the refrigerator is tie-tagged with patient identifying information that is not correct for the specific unit of blood. Another possibility is that the blood given to the courier who comes to pick up blood for a particular patient is not the correct unit for that patient. Release of the wrong unit may occur in as many as 25 % of the cases of erroneous transfusion (Linden et al., 2000).

Returning to Sam's case, recall that Laura Peterson stored the crossmatched, ready-for-release units for WM, 687115 in the refrigerator next to those for WN, 687116, as was accepted practice. This practice contributed to the risk of Laura choosing the wrong unit. It is a systems factor that created an error-provoking situation. Even when the intent is to store blood of different types separately, errors occur. Units may not be placed in the correct designated section of a refrigerator. It has been reported that 0.12% of units are stored in the wrong section (for example, an A-positive unit placed in the "O-positive" section) and are liable to incorrect release if not checked very carefully (Shulman & Kent, 1991). The blood bank is not the only place where this occurs.

Confusing storage of blood frequently arises in the operating suite, where blood for different patients undergoing surgery that day is stored in the same refrigerator. If a patient develops complications and has an urgent need for blood, it is easy for the incorrect unit to be selected as the nurse hurries to get the blood to the patient as soon as possible (Linden, Paul, & Dressler, 1992; Sazama, 1990). Units of different blood types look similar and the only difference is the label. Correct reading of the label is critical, but one often tends to see what one expects to see, as illustrated by Sam's case.

The presence of a means of checking to confirm that the blood released is that for the specified patient does not mean it is effective. Computers have become common in blood banks to provide electronic rather than paper records of the release of units of blood. Those computers are able to double-check the ABO compatibility between the unit to be released and the patient's recorded blood type, keep track of the need for specially treated blood such as irradiated or white blood cell-reduced blood, and provide an alert if an inappropriate unit is intended for release. Such technological safeguards work only if they are used.

One disadvantage of technology, such as the computer, is that one may become dependent on it and lose proficiency with manual methods. To accommodate times when the computer is down, blood banks must have alternative manual methods to release units; however, when the computer is down (or not used), staff may be even more prone to error than if the computer were not in use at all. This is what happened to Laura Peterson as she intended to save time. Thus, it can be seen that a combination of system factors predisposed Laura to make the error of choosing the wrong unit and failing to notice she had done so: She was assigned to perform unfamiliar tasks in the blood bank, her workload was high causing her to rush, her work was interrupted, units of different blood types were next to each other in the refrigerator, and the computer checking was cumbersome to use.

A final opportunity to detect the release of the wrong blood for a patient occurs at the bedside when the nurse verifies correspondence of the patient's identification information with the information on the unit. Often, as illustrated by Sam's case, a variety of circumstances preclude this opportunity for detection.

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  • Ren Wei
    Can blood bank test results are wtong?
    19 days ago

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