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A close call on a blood administration

Thanks to a responsible event report, we’re taking steps to make the process even safer.

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A unit of packed red blood cells without a patient label made its way to the bedside and was transfused. Luckily the blood type matched the patient’s, and there was no adverse event. An error like this, however, could have caused avoidable patient harm.

Please remember these key points of blood allocation and administration safety:

  • A blood product bag must have a tag or sticker label with patient identifiers on it during the allocation process and must stay on the bag throughout the transfusion process. This should be confirmed at the blood bank window or Haemobank at time of allocation, and again at bedside during the two-licensed-provider safety check before administration.
  • The unique identifier on the patient’s armband and the transfusion bag tag or sticker label must be the same (verified by two licensed providers) and be manually entered into the electronic health record.
  • Blood administration requires two licensed providers to verify the correct identification of the patient and the blood product.

For details on administration safety, see Blood Product Administration, Refusal of Blood Products, and Suspected Transfusion Reaction #400-PCS-NURS-0848.

Because an employee had the integrity to speak up and file a responsible event report (RER), Asante can look at improving safety processes for blood allocation and administration.

For details on RER reporting, see Responsible Event Reporting and Analysis in a Culture of Safety (ASANTE) 400-RISK-RISK-0001.

These processes include education and staff awareness, policy updates and Epic optimization. Please remember to submit an RER for incidents to help prevent harm to patients, staff and visitors.

blood
Don’t waste precious blood

In January to August of 2022 Asante saw 50 units of blood wasted through improper handling. This is almost double from 2021.

Please help reduce blood product waste during this time of national blood product shortage.

  • Return blood products within 1-10° Celsius.
  • Return blood products to the blood bank window within 30 minutes.
  • At ARRMC, blood products are never to be returned to the Haemobank. Always return them to the blood bank window.
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