Saving lives by means of safety precautions is emphasized by the health institutions. Particularly in clinical care a minute error can jeopardize lives of human beings. Though NHS has promised to serve the best interests of people, lapses in the patient safety seems evident. As a result, NPSA proposed seven steps to safe guard precious life.
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Over all the literature discusses the patient safety measures, human and system factors contributing to minimize the performance and precision of care administered. During 20th century sudden rise in blood transfusions are evident. Blood is regarded as an important organ. Transfusion is a multi-step process where risk or complications are common. It discusses all the important steps in assessing the human and system errors. Systematic review is done by estimating the risks and proposes a solution of bloodless surgery which is last option to escape from worries of transfusion.
The key terms used for search are patient safety, safety culture, blood transfusions, ergonomics, bloodless surgeries, organizational factors and human incidents.
The health sector is a highly pressurized, complex system where in which the potential for error and accidents is ever present. Statistics on International Research suggests that ensuing patient safety is one of the most important challenges faced by the healthcare today, not only in the United Kingdom but also worldwide. It was observed that the root cause of various events and accidents together with a majority of mistakes taking place in medical environment is the system itself-a system whose flaws eventually lead to a “human error”. The Patient Safety initiative is an innovative, proactive approach that provides basis for eliminating the flaws from the system before they result in to needless tragedies. According to World Health Organization (2011), Patient safety can be defined as a “fundamental principle of health care” (WHO, 2011). Precisely, the improvements concerning to patient safety demand a complex-system of wide effort, environmental and safety risk management, including infection control, safe and effective use of medicines, clinical practices and care. Nevertheless, this new patient safety perspective was been developed in United Kingdom through an initial study, commissioned by the Department of Health and Design Council, to deliver ideologies and recommendations for a design approach to minimize the risk of medical error and to promote patient safety across the National Health Service (Department of Health, 2006).
On the other hand, Risk an inherent part of health care may lead to severe complications while delaying them might be even more dangerous. At moment, in NHS controlling safety and estimating the risk has become internal process of supporting patients in hospital settings.
To improve standards in patient care and for reviewing, documentation of risk form the basis for future investigations. Risk assessments carefully examine the systems to identify the factors that could potentially cause or contribute to patient harm (Department of Health, 2004). These assessments highlight whether adequate precautions are being taken to ensure timely and safer provision of care. Additionally, it indicates further measures needed in future to prevent harm and risk to the patients (Department of Health, 2006). Seven steps by the National Patient Safety Agency were published in 2004. Gives evidence of the risk involved and steps to prevent potential harm by integrating the management of risk, patients involved and the solutions proposed for incidents (National Patient Safety Agency, 2004). Within NHS, Risk Assessment is highly essential as it facilitates the practitioner to minimize both consequences of an adverse effect and risk itself. Risk Assessment provides an early warning system and thus maximizes the probability of positive outcomes. Thus, Risk Assessment tool can be used effectively with sound clinical judgment connected with experience of assessing risks. In essence, managing risks of ward-base and evaluation of patients is vital aspect of the tool (Royal College of Nursing, 2004).
Major concern is that blood is contaminated with infectious diseases like AIDS, hepatitis etc. Though screening being implemented, there is a risk involved while donating blood. Dr Gordec identified “patients willing to donate blood being infected and not yet developed antibodies could be detected through screening”
Blood Borne Disease:
A great stride in medicine field has invented new surgical methods and procedures for transfusions. It became a multibillion-dollar industry. Soon, transfusion-related diseases came to the fore. During the Korean War, nearly 22 percent who received plasma transfusions developed hepatitis. By1970’s, the U.S. Centers for Disease and Control estimated death due to the hepatitis infected blood, 3500 a year (Awake 2002: Published by Jehovah’s witnesses).
Case study of heart surgery related patient
The rate of mortality is high in patients undergoing heart surgery and kidney transplantation. The incident is treated as adverse event which is not happened at the beginning levels of transfusion. Although the preliminary checking is done, the rate of mortality is high. Patients diagnosed with coronary syndrome were routinely given blood transfusions. Studies published by JAMA admits” that folks often choose transfusions are at higher risk of dying when compared with those who refuse”. Doctors participated in the study published findings saying: “We caution against the routine use of blood transfusion to maintain arbitrary hematocrit levels in stable patients with ischemic heart disease”.
Nigerian case study:
Case of a baby girl infected with HIV positive in Nigeria was reported in the Awake 2008 article titled:”HIV- Screened Blood Safe”. Soon after the birth, the baby found to be jaundiced. The doctors prescribed transfusion. As father’s blood is incompatible, hospital authorities ordered blood from blood bank. Post transfusion, the baby detected HIV positive, though parents were HIV negative. Investigation is done and the Nigerian Tribune reported a virologist saying: At the time of donating, the donor was at the window period of HIV infection”.
The window period for HIV infection, is time period taken by the immune system to recover the antibodies for antibody test. It may take 2 to 8 weeks and it varies from person to person. So the screened blood is no safe and carries risk. The San Francisco AIDS Foundation warns: “During the test, HIV infected person cannot be detected during that time. In fact, often people are infected at this period of time.
The pre-check for immune factors is small mistake but the implication of transfusing the blood has resulted in adverse result which may result in death.
Case study of Transfusion-related lung injury (TRALI)
Case study of patients’ administered in hospital for receiving blood products, particularly plasma-containing products for hemolytic reasons. This is quite interesting case, after transfusing blood, the patient contracted transfusion-related acute lung injury (TRALI). When careful investigation is done, though careful administration of right blood and patient identification is carried, the blood cells from the donor reacted with recipient’s white blood cells was evident. This resulted in the size of the lungs which allow the fluids to enter and may lead to death if not treated correctly.
This incident is classified as adverse event, where careful observation is vital in delivering services. The nurse should take a note of reactions and report to higher staff and doctors. Based on the reaction of patients, the nurse should stop transfusing the blood as a precaution measure
According to the Health and Safety Executive (1999, p. 2), ‘Human factors influences the behavior of individuals or an organization based on factors like organizational, environmental and job which affects the health and safety of employees and employers. A simple way to view human factors is look into three aspects: the job, the individual and the behavior’ (Health and Safety Executive, 1999).
Categorizing Human Failure
It is very important to understand that human failures in relation to transfusion process are not random and there occur specific patterns for their implementation (Manser, 2009). Different types of failures that lead to major accidents in Healthcare sector are worth knowing:
Unintentional Errors like slips/lapses, mistakes are basically unplanned actions and these must be eliminated during the training process of human factors. Errors usually occur during the accomplishment of a familiar task such as forgetting something or omissions, maintenance, calibration and testing errors. Mistakes, on the other hand are the errors of judgment and decision making and they appear in situations where nurse behavior is based on familiar procedures or unfamiliar situations where in which decisions are formed form the first principles and lead to miscalculations. By training the nursing staff and other health professionals in Transfusion department, these types of errors can be avoided (Mc Cormick, Wardrope 2003).
International Errors involve violations and these differ from the above type of errors as these are well-meaning failure such as non-compliance of procedures or taking a short cut of Transfusion process.
These are rarely willful (like sabotage) and usually occur from an intention of getting the job done quickly despite of consequences. These Violations cane be Routine (behavior in opposing to a rule and procedure), Exceptional (that prevail unusual and unpredicted circumstances), Situational (occur as a consequence of factors dictated by workers) and Acts of Sabotage (self explanatory and complex) (Manser 2009).
Clinical blood transfusion contains multiple steps and is prone to error. Various studies showed most errors occur outside the clinical laboratory. Errors are likely to happen while collecting the blood components from storage facilities, performing transfusions and while monitoring patients before and after transfusion.
The common fear is that patients get infected while receiving the blood components. It occurs very rare. SHOT acknowledges “that only 1.4 % infected out of 4,334 adverse events between 1996 and 2007”. The greatest risk lies in human error, administering blood to wrong patients or not intended to someone else, accounts to 62.7% of reported cases (SHOT, 2008)
While ensuring blood is administered to the right patient, scrupulous enquiry into patient details is mandatory. Identifying patients is vital and must be confirmed when pre-transfusion is taken, collecting the specimen from storage areas and when blood is injected.
Checking the blood bag:
Bacteria infected transfusions are major cause of deaths. The staff should remain vigilant and check for the contaminated blood components of red cells and platelet units (SHOT 2008). Nurses should check the blood bag for any discoloration or clumping and also expiry date of the product.
The person/ relative who retrieve the blood from the bank must take a written evidence of patient’s identity. This must be check against the patient’s identification band exactly. Details of patients must include such as first name, surname, date of birth and unique identification number (BCSH 1999). It minimizes the risk of being wrong blood collected and giving it to the wrong patient.
Pre-administration check is vital in ensuring safety measure while donating blood. It includes checking the patient information on the blood pack against the label of the recipient. The staff can enquire with the patients about their details and cross-check with the identification band. Due to ambiguity or unconscious state of recipient, identity can be verified with second staff member and via recognition band.
Based on compatibility report or patient’s note must not be considered as final checking procedure (NPSA, 2006). Nurse should remember the main 2 points.
No identification band – no transfusion, and always confirm with identity band.
The blood group and donation number on the compatibility tie-on tag should match the blood component.
If discrepancies are found during the process, the nurse should stop immediately and contact the transfusion laboratory. For example: DOB not matching with identity band. Continuity without distraction is important in verifying the information. In critical conditions, interruption can be allowed. Sometimes it makes them distract to perform checking from beginning to end.
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Studies show there are differing opinions of observing the patents during transfusion. It is generally agreed observations are recorded before administering. Rowe and Doughty (2000) highlights rate of response to reactions caused by blood without proper monitoring techniques. To respond quickly by the staff constant observation is mandatory.
Prior administration checking blood pressure, pulse rate and temperature is recommended (BCSH 1999). During the entire process for every 15 minutes the above recommendations are repeated. Making notes of vital signs for every 15 min is suggested during the first hour and every 30 min from second hour (Castledine 2006).
War strategists say that humans are likely to sleep in early hours of morning (3.00 am to 5.00 am). The sleep factor makes the observation bit difficult at night times. During delayed transfusion reactions being vigilant is challenging.
System is defined as interaction with the physical, social and organization environment in which individual operate. It deals with Information technology devices, protocols, legal procedures, working environment, education and training etc.
Reducing the medical adverse drug events (ADE) at St. Joseph’s medical centre, Illinois has led to automation of process. The medication process is quite lengthy and incidents such as unavailable patient information, miscommunication of medication, labeling and storage are often repeated.
Information technology cannot replace the humans in critical care, but can reduce the repetitive tasks such as entering the pre-requisite details, including checks for problems. Humans are better than computers while taking complex decisions (Bates 2000). Reliance on individual is emphasized rather than automated systems when explaining errors and accidents (Parker and Lawton 2006).
CPOE (computerized physician order system) has made great impact in prevention of medication errors, while orders are written online. The information is structured, contains details about the drug, dosage and frequency. Finally each order is verified for allergies and quantity of dose for patients suffering with kidney and liver problems. The invention of CPOE has resulted in 55% reduction in medication errors (Bates 1998).
Decision to transfuse:
The decision not to transfuse must outweigh the risk of transfusion. Each blood samples should be given to patient after consideration and when there are no alternatives. Further guidelines and indications can be found at www.bcshguidelines .org.uk and www.sign.ac.uk.
It is better to discuss the treatment option before a decision is reached for prescribing blood components in clinical practices (McClleland 2007). To gain consent for treatment, the patient (parents/guardian) should have access to information about the risks. The patient has the right to refuse the transfusion by assessing the risk factors and alternative techniques. Some may reject the based on religious grounds or because of risks. In cases like these, the nurse should refer to local hospital policy for advice (Grey et al 2007)
Religious group Jehovah’s Witness, because of their bible-based faith they keep abstaining from blood components. They have a durable power of autonomy (DPA) and the Advance Medical Directive/Release card as into a single legal document, which explains their stand and treatment options.
Local hospital policies:
Blood is given voluntarily in UK. The hospital authorities have to ensure the blood is used effectively and for the benefit of patients. The nurses should be aware with local hospital policies related to effective use of blood, storage and transportation. Each blood unit is precious; if unused it should be sent back to laboratory to maximize the use by other patients.
“There is often blame culture. When things go wrong, people may threaten them with disciplinary measures or termination from services. Such individuals should be held accountable, but it acts as deterrent in reporting the adverse event” (Department of Health, 2007, p.77).
The communication and mutual respect is important, to be an effective team player. Some junior doctors have not found good reasons to transfusion, and are in dilemma about the treatment. They have fear of challenging the treatment options and often budge. In situations like these open debate or discussion should be welcomed by the higher officials, which benefits the patients. There are cases, unnecessarily blood transfusion are opted repeatedly which risks the patient recovery.
Human errors are inevitable though much care are precision are followed. Blood is an organ and complications are expected while transfusing. There has been a debate about whether blood transfusion is really necessary. Jehovah’s witnesses are known world-wide for bloodless surgeries. They have various alternative techniques. In October 2006, Reforma reported more than 30 blood transfusion alternatives. They include cauterizing blood vessels, covering organs with special gauze that releases chemicals that inhibit bleeding, and using blood-volume expanders.
Time magazine says “the total operative cost for the blood transfusion, the bill comes between $1 billion and $2 billion annually”. Sharon Vernon, director for bloodless medicine admits “that people are becoming aware of the benefits of bloodless surgeries and its cost cutting environment. The recovery of people is commendable”
Education and Training:
The nurses and midwives needs to be updated with skills and competencies to understand the peri-operative conditions of blood transfusions. To participate in clinical transfusion, NHS Quality Improvement Scotland in 2006 has initiated education initiative and equivalent roles which is a prerequisite for nurses.
Role of patients:
Ethics published by NMC are available in respecting the patient rights when opting treatment. The patient can play an active role in reducing the accidents by making scrupulous search into the options available, benefits and risks associated. For further information, leaflets are available at hospitals and web resources can be helpful.
Patient safety is vital in providing good care. The NHS has worked with NPSA to implement the guidelines for preventing of errors or hazards. Though systems are designed to make error free, complete elimination of mistakes is not possible as we have tendency to err. The literature discusses the human and system factors of blood transfusion. Though pre-administration check, identification of blood bags are done properly, immune factors of the donor has to be tested. The whole process is riskier and involves cost which is burden. Despite safety precautions, it is best to go for blood less surgery which is infection-free; recovery from surgery is almost double and the total cost of surgery is affordable. Competency based training and education enables the nurses and staff to deal successfully with adverse reactions.
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