Blood Transfusion Confusion

A married couple, Mr. and Mrs. Harvey, were brought to the emergency department of a Level II trauma center after an automobile accident involving a three car pile-up. Mrs. Harvey was in the front passenger seat and presented to the ED with multiple contusions and a fractured pelvis, but appeared to be hemodynamically stable. Mr. Harvey had been in the driver’s seat and absorbed most of the impact. He was comatose, with internal bleeding and hypovolemic shock. Although both patients were typed and crossed, as per unit policy and procedure, it was apparent that only Mr. Harvey was in need of an urgent packed red blood cell transfusion.

The unit was extremely busy and short on two nurses for the shift. The Harveys were placed in a large trauma bay with several beds. In the commotion of stabilizing and assessing both patients, the blood typing tube for Mrs. Harvey was labeled with the sticker for Mr. Harvey. After the specimen was sent to the lab, the packed red blood cell transfusion, based on Mrs Harvey’s blood type and cross match, was delivered to the unit for Mr. Harvey’s transfusion. In the meantime, two gunshot wounds as well as additional motor vehicle accidents presented to the ED.

The nurse originally assigned to the Harveys went on break and Mr. Harvey’s condition began to deteriorate rapidly. The nurse covering the bay was unaware that two of the patients in the bay shared the same last name. She glanced briefly at the name on the bag and matched the last name with the wrist ID band on Mr. Harvey’s wrist. The transfusion began and within minutes Mr. Harvey coded.

Every year, nearly 5 million people in the United States receive life-saving blood transfusions. Sometimes, however, human error transforms a life saving procedure into a death trap. Some experts estimate that about 25 patients die each year in the United States from blood transfusion errors. These errors are usually due to misidentification of type-and-crossmatch samples, laboratory errors, or misidentification of the transfusion recipient.

Elimination of transfusion errors is one of the 2009 -2010 National Patient Safety Goals. The Joint Commission requires that all facilities develop an objective method to match the patient to the blood or blood component to be transfused. The blood or component must also match the order. Two unique patient identifiers must be used, and two registered individuals must independently identify a match between the patient and the blood; one of which must be the professional transfusing the blood. The second individual must be qualified to participate in the identification process.

The Joint Commission has developed guidelines to improve compliance. These guidelines include becoming familiar with your organization's standard unique identifiers, and reviewing organization Policy & Procedure for acceptable persons acting as the second identifier and what training and/or license/certification they must possess. If only one person is available, there are written exceptions for managing the double check process with automated technology. The Joint Commission also recommends reporting all blood transfusion reactions and follow organization policy & procedure for specimen management.