Over the past few weeks I have edited a five-part series on blood transfusion, which has reminded me of the multiple points at which things can go seriously wrong, from taking a cross-match blood sample to administration of a blood transfusion.
I was surprised to see how often Serious Hazards of Transfusion (SHOT) receives reports of patients being given the wrong blood. In 2012, 252 incidents were reported and, of these, 151 errors originated in the clinical area.
The consequences of receiving incompatible ABO blood products can be life threatening, and NHS England has labelled these errors never events.
Yet in 2012, 10 incidents occurred and three of these patients went on to experience severe harm as a result of the inadvertent transfusion of ABO-incompatible blood components. In two-thirds of cases transfusion errors were caused by human error, often due to misidentification of the patient.
Interestingly, NHS Blood and Transplant and SHOT are seeking to empower patients with a campaign encouraging them to ask health professionals “Do you know who I am?”. They make it clear that patients should understand what the blood samples are being taken for and give their consent.
It is surprising that despite policies that dictate rigorous checking procedures and careful observation of patients, errors continue to occur. Clearly we can’t rely on patient empowerment to ensure that the right patient gets the right blood, but we have a responsibility to ensure we are up to date with the latest evidence on the management of transfusion.
To support you in this Nursing Times is publishing a five-part series on blood transfusion written by experts from the NHS Blood and Transplant Patient Blood Management Team. It aims to help you provide evidence-based care to your patients and help avoid errors that can lead ultimately to loss of life.
The series covers:
- Consent for transfusion (published 3 September)
- Processing, storage, testing and selection of blood components (10 September);
- Safe administration (17 September);
- Transfusion reactions (24 September);
- Patient Blood Management(1 October)