Prescribing incorrect (un-irradiated) blood components may be caused by a myriad of deficiencies, including:
- Lack of knowledge by the ordering physician that irradiated blood is needed (education and training deficiency)
- Failure of the need for irradiated blood to follow the patient and be flagged for the transfusion service laboratory (communication deficiency)
- This problem is exacerbated if patients are treated in two different hospitals, especially if the hospitals are in different health regions. See comment by a member of TraQ's National Steering Group.
- Failure of the need for irradiated blood to be flagged in the laboratory information system (communication deficiency)
- Failure of the transfusion service laboratory to retrieve the patient's history in the paper or electronic patient records human error resulting from underlying factors, e.g., training deficiency, stress, overwork, carelessness)
- Failure of laboratory information system to correctly identify patient as requiring irradiated blood components (electronic communication deficiency)
Strategies for correcting communication deficiencies are presented below.
- Communication tools for patients on fludarabine
- Examples of specific communication tools
The 2003 SHOT Report 1 includes many cases offailure to provide irradiated components for patients treated with a purine analogue. Patients at risk for TA-GVHD include all patients receiving fludarabine and perhaps all patients receiving nucleoside analog therapy. Problems related to fludarabine is an on-going problem as the 2000-2001 SHOT Report 2 included 33 cases of failure to request the appropriate component with the most common error being failure to request irradiated components for patients at risk, including16 cases where the patients were on
Related learning points from SHOT 2003 Report>1:
Robust systems are needed to ensure that patients at risk of TA-GVHD receive irradiated cellular components. The pharmaceutical industry and hospital pharmacists have important roles to play.
There must be effective communication when patient care is shared between hospitals, to ensure that relevant information is available to all concerned.
There is a need for education regarding guidelines and policies on special transfusion requirements.
Patients should, wherever possible, be educated and empowered regarding their special requirements and staff should take note of information from patients.
Transfusion laboratory IT systems should provide effective ?flagging? of special requirements and alert staff to select appropriate components.
Recommendations from the SHOT 2003 Report1
SHOT recommendations provide a framework for the type of communication tools needed to prevent these errors and are directed to
- clinicians prescribing purine analogues and administering blood transfusion
- hospital transfusion teams
- pharmaceutical industry
- suppliers of laboratory IT systems
Incorrect blood component transfused:
Prevention of TA-GVHD in patients receiving purine analogues is the responsibility of prescribers, but can and must be supported by the pharmaceutical industry and pharmacists and by suppliers of laboratory IT systems. All patients should receive an information card and leaflet and haematologists must ensure that there is an effective system of flagging special transfusion requirements in the laboratory. Referrals for shared care must include timely communication of all relevant information.
A frequently reported problem in this category was a failure to notify the transfusion laboratory of the need for CMV negative and/or irradiated components. This is a commonly recurring theme both in "near miss" events and in full incidents and often indicates a need for improved communication between hospitals where patients are receiving shared care. The majority of errors in this category were made by junior doctors, usually senior house officers, highlighting the need for education and training for medical staff requesting and prescribing blood components.
Transfusion-associated graft versus host disease:
Good communication is required in all cases but particularly when patient care is shared between different hospitals. Hospitals must have clear protocols to ensure accurate information relating to this risk is communicated in a timely manner. Provision of the BCSH/NBS patient card and leaflet are also recommended.
The following are examples of communication policies and procedures designed to provide safe transfusion for patients on fludarabine therapy.
Source: Canada's Transfusion Safety Officer (TSO) mailing list "transfusion" (edited to preserve confidentiality):
We are trying to develop a new process to ensure that the transfusion service is aware of patients who have had bone marrow transplants and patients who are on fludarabine. As we do not perform BMT we are not always aware that patients require irradiated blood products when they arrive here.
We are trying to work something out with pharmacy to notify the transfusion service through Meditech whenever fludarabine is ordered. Hopefully this will help, however, it will not solve our issue around transplant patients.
Any suggestions? How do your transfusion departments deal with this issue?
We needed to address this very issue recently, particularly about whether a patient was on or had recently been on Fludarabine. Unfortunately I couldn't get any specific guarantees regarding notification from Pharmacy. However, I have discussed the issue with our cancer physicians and reminded them of the need to specify irradiated components for such patients and this has worked well since then.
We are also a Meditech facility, so I would be interested in any flags, warnings, or pop-up boxes that you can figure out that will make this process easier. In addition, I also add information to the Blood Bank History comment if I come across such patients when reading through physician notes in Meditech.
Our bone marrow and stem cell transplant patients who receive autologous transplants return to us one day post-transplant.
- About 2 weeks prior to the transplant we receive a notification letter from the transplant program advising us of the patient's name, health care number, date of transplant, and transfusion requirements (anti-CMV negative, irradiated).
- The letter is filed in a binder and a card is created for the patient's file.
- Markers are placed in the Meditech history to indicate the type of blood product required. There is also a comment attached to the history indicating the transplant date and transfusion requirements.
- Three or four days prior to the patient's return, the nurse manager on the oncology unit confirms the date the patient will be returning with the blood bank.
This seems to work very well for us. Patients who have allogeneic transplants recover at the hospital where the procedure is performed so the notification process for them is not always as efficient. The staff of the oncology clinic are usually very good about providing verbal notification and the same process is followed for flagging patients in Meditech.
Our pharmacy department notifies us when a patient is started on fludarabine therapy. We then add a special instruction into our LIS to say patient needs irradiated blood and is on purine analogues
The BMT patients are made known to the transfusion service (TS) via a form that is faxed from the Transplant Coordinator.
- We also ask that they send a TM-generated form called "Request for Special Blood Products".
- This form provides space to request either CMV-negative or irradiated (or both) products, to indicate why the request is being made, who has made the request, and who sent the request (doctor and clerk who fills out the form) and when the need is to start.
- When the form is received in the TS,the technologist updates the blood bank record card and puts a marker in the computer that will block issue of anything but product that meets the special need.
- A letter is sent to the patient's physician and the patient explaining their need for special product and asking them to show a wallet card that accompanies the letter.
- We also have an agreement with the transplant group that they will encourage use of a medic alert but many patients decline to wear these.
For fludarabine and cladribine, renal transplants we ask the
- Physician or nurse clinician to notify us when the drug is prescribed via the same form and follow the same documentation in the lab.
- On one site there is a pharmacist who supports the BMT program so she encourages notification but on the other sites it rests with the doctor or nurse clinician.
- Pediatrics works in the same way although there is a tendency for them to order CMV-negative or irradiated and we ask them to send the form.
This process was supported with inservices to all the nursing staff in the various areas, periodic repeats - some doctors are good at it, others less so. Since we use the same form for CMV-negative, we tend to be vigilant about reviewing requisitions for "new leukemia" in case they forget to send form at diagnosis and try to follow-up with education.
Additional Responses (received after Case O2 went live)
We find this is more and more an issue when our patients move from place to place for their care. At any given time, most of our patients are not local. For us, the first time we usually hear of a patient is when they show up a few hours prior to their procedure. If the patient requires anti-CMV negative or irradiated components, there is not enough time to get if from our blood supplier in a city 355 km (221 miles) away. We try to keep special components on hand but it is constantly a guessing game.
One thing we have suggested is to issue cards, similar to antibody cards, to patients who require any type of special handling such as requests for premedication, irradiation, etc.
Source: UK National Blood System Hospitals website
Information for patients needing irradiated blood (NBS brochure)
The need for effective communication mechanisms for patients with special transfusion needs is required by various transfusion safety standards, such as CSTM Standards for Hospital Transfusion Services, v. 1(reproduced with permission):
CSTM (H4.1.1): There shall be an established policy defining when irradiated cellular blood products are required for the prevention of transfusion-associated
graft versus host disease. (referenced to CSA Z902-04 #11.7.1)
CSTM (H4.1.4):There shall be an established process to ensure that recipients of irradiated products continue to receive irradiated products as long as clinically indicated. (referenced to CSA Z902-04 #11.7.3)
AABB Standards (# 5.16) also requires that there be a mechanism to ensure that patients with special transfusion requirements receive only blood and components that meet those requirements for as long as clinically indicated.
TraQ self study questions
1. Which of the following have studies shown is most often the underlying cause of failure to request irradiated components for patients at risk of GVHD?
2. What are some long-term strategies for preventing communication errors that cause transfusion and other medical errors?
3. What role, if any, can patients play in increasing transfusion safety?
4. List four health professions that play a role in safe transfusion for patients taking fludarabine.
5. How can the transfusion service laboratory increase transfusion safety for patients requiring irradiated blood components?
Proceed to Summary
1.Serious Hazards of Transfusion. Annual report 2003.
2. Serious Hazards of Transfusion.Annual report 2000 - 2001.