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This case derives from an unpublished study case created by Amélie Rivard, Nurse Clinician in charge of Transfusion Safety, McGill University Health Center. Amélie and her colleague Anna Urbanek work as Nurse Clinicians in charge of Transfusion Safety at MUHC. Amélie Rivard retains copyright for the original case.
TraQ has copyright for this web-based case, which has been fictionalized to enhance its educational value. The described events and practices did not happen at MUHC.
Special thanks to the following who kindly provided advice, information, and ideas for the case. The discussion benefits from their valuable input (errors or misstatements are entirely those of the author):
The essentials of the case: (Hover mouse over words to expand to a definition)
A 26 year old single female living with her parents was admitted for a CSF leak from the nose, fever, lethargy, neck stiffness and pain. She had multiple surgeries in the past and her health status was poorly controlled. She was admitted to the ER on Jan. 9 for brain surgery. A diagnosis of meningitis followed within a few days.
On Jan. 12 a CT scan of the head showed a large amount of intracranial air in the subarachnoid space and ventricular system. There was a moderate hydrocephalus and the size of the ventricular system had progressed. Between the Jan.1213 a drain was inserted via a frontal burr hole, the tip of the drain located in the third ventricule. On the following CT scan the volume of intracranial air had slowly decreased and the size of ventricular system was reduced. The morning of Jan. 19 the physician decided to close the drain and the patient stabilized.
In the afternoon of Jan. 19 patient hemoglobin was dropping quickly and the physician decided to transfuse 2 units of packed red blood cells (PRBC).
Hemoglobin 79 g/L (120?160)
Hematocrit 0.270 L/L (0.370?0.470)
Platelets 503 x 109/L (140?440 x 109/L)
The patient had been tested once before in another hospital as O Rh positive. A type and screen was done, 2 units of packed red blood cells (PRBC) were crossmatched, and one was sent to the patient's ward.
The first unit was started at 10:55 am. Vital signs were recorded:
As the nurse was unable to get an infusion rate faster than 1 drop/10sec., she flushed the port-o-cath with 350 U of heparin. The rate did not increase and she replaced the needle with no success. Finding a new IV access was unlikely because patient had poor vein access and would have required a new port-o-cath insertion or a central venous access, not considered possible as the patient was already unstable.
The nurse called the attending physician to explain the situation and charted the conversation as follows:
The nurse followed the order and ran the transfusion over a little more than 8 hours. No further vital signs were taken.
The second unit was started by the same nurse (who was working a 12-hour shift) at 19:15 h. Vital signs were taken with no untoward results. No further vital signs were taken until 20:30 h. when the patient started shaking and stiffness was noted. The transfusion was stopped, the physician was contacted, and the nurse followed standard procedures detailed in the facility's nursing manual.
Vital signs were
The patient presented decerebration but no clonus opisthotonos , no bronchospasm, but loss of consciousness. The patient was given Benadryl IV, bolus 250cc and solumedrol IV push. The patient was then transferred to an intensive care unit.
In the ICU, patient was covered with cooling blanket and received Lopressor x 4 doses, Fentanyl push, Propofol, Dilantin, IVIg boluses, Tylenol. The patient was finally intubated and put into artificial coma. Blood culture was done and blood bag returned to blood bank for investigation.
Upon detecting the suspected transfusion reaction, the transfusion service (TS) was contacted and the TS performed a transfusion reaction investigation according to its policy and procedure manual, eliminating a hemolytic transfusion reaction as the cause.
Because a bacteriogenic reaction was suspected due to fever subsequent to a prolonged transfusion time (8 hrs.+), the hospital microbiology laboratory performed gram stains and cultures of both PRBC contents, as well as recipient blood cultures. All were negative.
Subsequent analysis revealed that the nurse in question required remedial training related to resolving slow running transfusions and critical thinking in general, and also required re-training for how to monitor and document transfusions.
A more systemic problem was identified regarding the responsibilities and related skills of health professionals to provide checks for patient safety as part of the healthcare team. In-service interdisciplinary educational sessions were held to discuss and resolve the issues.
To test your knowledge and as an advance organizer for the discussion section, read and consider these questions:
Proceed to Discussion (includes interactive questions with feedback):
This case study presents a scenario in which a nurse did not follow several key transfusion protocols and procedures, including adhering to the time limit for transfusing blood, monitoring vital signs throughout a transfusion, and questioning orders that contradicted hospital policies and procedures.
Based on laboratory results and a multidisciplinary discussion, staff concluded that a febrile non-hemolytic reaction had likely occurred after the second PRBC and had triggered subsequent events:
Further analysis resulted in individual re-training and a system-wide education program on responsibilities and skills for providing interdisciplinary checks to ensure patient safety.
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(also see individual discussion sections)
Agency for Healthcare Research and Quality.One dose, 50 pills (Morbidity and Mortality Rounds on the Web)
Altogether for Health(editorial, Student BMJ, Jan. 2006)
Bloody Easy Online Courses (Sunnybrook & Women's College HSC, Toronto, Ontario, Canada)
Calgary Laboratory Services. Policies relating to transfusion of blood components and products
Case 108 - Transfusion reaction (University of Pittsburgh)
CBBS e-Network Forum
Canadian Blood Services:
Collaborative care receives stamp of approval in CMA, CNA study involving HIV/AIDS (CMAJ 1996;154: 21?7)
Collaborative care means collaborative training (Health Council of Canada)
Disruptive Clinician Behavior: A Persistent Threat to Patient Safety (July /August 2006, Patient Safety & Quality Healthcare)
Interprofessional collaboration (CNA position statement)
INTD 410 (University of Alberta, Edmonton, Canada)
Perlow D, Perlow M. Courts' perceptions of the responsibilities of nursing practice
Royal College of Physicians and Surgeons of Canada (RCPSC):
Scope of practice:
UK: 2004 SHOT Report