Case Study O4: Death following transfusion of group-specific RBC in a dispensary-only facility
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This is the only case on the new website whose links have not yet been checked - this will happen shortly.
- Case Study O4 deals with issuing red blood cells (RBC) in emergencies and related blood safety standards.
- This case was motivated by a poster at the 2005 AABB meeting by Bev Padget, Transfusion Medicine Proficiency Program Coordinator, Alberta Laboratory Quality Enhancement Program and Dr. Judy Hannon, Medical Director, Canadian Blood Services, Edmonton, AB, Canada*.
Case O-4is the fourth in the "Other cases" series (cases or reports initially published elsewhere). The original report forms only the starting point for the TraQ case.
- Included are educational enhancements designed to emphasize learning points about issuing blood in emergencies and assessing the competency of staff in non-testing facilities.
- The format differs from those of typical serologic cases (which tend to focus mainly on a patient's laboratory and clinical data and the resulting serologic investigation). Instead, practices related to the case are discussed, particularly as related to blood safety standards and regulatory issues.
- Learning outcomes
- Original reportCase scenario
- Questions to be considered
- Further Reading
Upon completion of this exercise, participants should be able to do the following:
- Discuss the role played by patient blood group records in pretransfusion testing, including their importance in preventing misidentification
- Explain precautions related to the use of records
- Provide examples of blood safety standards for issuing RBC in emergencies
- Discuss standards and regulations for returning blood components to inventory and reissuing them
- Describe when it is essential to obtain medical consultation in the TS, and provide examples related to emergency transfusion
- List the health professionals with transfusion-related responsibilities and describe some of their mainresponsibilities
- Discuss the scope of transfusion service and medical director responsibility for off-site laboratories and transfusion-related patient care
- Describe the 4 elements needed for legal negligence to occur
- List several blood safety standards related to training and competency assessment in the TS
- Differentiate between proficiency testing and competency assessment
- Which types of knowledge and skills should competency assessment programs assess?
- List effective characteristics of paper challenges used in proficiency testing
- Discuss strategies for facilitating competency assessment in small dispensary-only facilities
- Discuss challenges related to implementing and maintaining best practices in dispensary-only facilities
This case was motivated by a poster presentation at the 2005 AABB meetingconcerning an external quality assessment program involving paper challenges for 85 dispensary-only laboratories in four Canadian provinces1. Some of the key findings:
- Emergency processes: 48% would not obtain physician authorization for emergency release
- Emergency processes: 22% would transfuse ABO-specific RBC based solely on historical records
- Storage and handling: 87% did not include all criteria for return of RBC for reissue
Because many transfusion services are now regionalized and consist of a central testing facility with multiple dispensary-only satellite facilities, a case study on best practices in non-testing facilities seems timely.
The essentials of the case (hypothetical case derived from the poster*):
A 55-year old male patient (JS) was admitted to hospital after a multiple-vehicle car accident with multiple fractures and severe hemorrhaging into his abdominal cavity.A group and screen was done 5 years earlier and laboratory records showed him to be group A Rh positive, but no blood was transfused at the time. A 25-year old female victim of the same accident without a prior record of transfusion was admitted at the same time, also suffering from multiple fractures and head trauma.
The hospital laboratory consists of a core lab that routinely performed basic hematology and chemistry tests but no blood bank testing. However, the lab does store and issue blood that is tested in a central transfusion service 100 km away. Normal turn-around-time for STAT crossmatch RBC is approximately 5-6hours (including driving time).
The laboratory received an emergency request for uncrossmatched blood (3 RBC units for JS and 2 for the female patient). The only blood that the laboratory had in storage were 2 group O Rh negative RBC (standard emergency supply) and, by chance,3 group A Rh positive RBC that had been crossmatched by its central transfusion service for another patient having elective surgery the next day.
Because of the urgency, the two core laboratory technologists on duty decided between themselves to issue the
- 2 O Rh negative units to the female patient
- 3 A Rh positives (previously crossmatched for another patient) to JS
At 15:30 h, all 3 A Rh positive RBC for JS were sent to the operating room as were the 2 O Rh negative RBC for the female patient.
Shortly thereafter pretransfusion samples and crossmatch requisitions were sent to the central transfusion service via local ambulance.
JS underwent surgery and received all 3 A positive RBCwithin an hour. Clinical staff did not question the rapid issue of ABO-specific RBC, although they were likely aware that the laboratory did no on-site testing.
At 16:30 h the female patient died on the operating table from traumatic brain injury before being transfused. The O Rh negative RBC, which had been left on a counter in the OR, were returned to the laboratory and entered back into inventory.
At 16:45 h the 2 O Rh negative RBC were then re-issued and transfused to JS, who was still in the OR.
At 16:50 hours, the central transfusion service was finally telephoned and told to expect the in-transit crossmatches and that the dispensary's emergency supply of O Rh negative units needed to be replaced. The call had not been made earlier as the technologists were swamped performing other STAT tests on the trauma victims. The central lab was also told that JS had received 3 group A positive RBC, since he was a known A Rh positive, as well as 2 O Rh negative units.
Central transfusion service
Upon receipt of the pretransfusion samples the central facility typed JS as group O Rh positive. The medical director of the central TS immediately notified the patient's physician about the likely ABO-incompatible transfusion with advice to monitor and treat the patient for a hemolytic transfusion reaction. Subsequent testing on a freshly drawn sample later that night confirmed JS as group O Rh positive.
JS survived surgery but died the following day due to complications from a severe hemolytic transfusion reaction.
To test your knowledge and as an advance organizer for the discussion section, read and consider these questions:
Can group-specific RBC be issued based only on historical blood group?
Which requirements must be met before blood components can be returned to inventory and reissued? (list 4 or 5)
- When RBC are released prior to completing pretransfusion tests, what standards, if any, relate to the requesting physician?
- What mechanisms are available to facilitate the competency of staff involved in blood transfusion in non-testing facilities?
Proceed to Discussion (includes interactive questions with feedback):
- Part 1: Use of historical blood groups
- Part 2. Issuing blood to the OR
- Part 3. Medical consultation
- Part 4: Transfusion-related responsibilities
- Part 5: Training and competency assessment
This case study has presented a scenario of a fatal hemolytic transfusion reaction occurring in a dispensary-only facility that lacked adequate TM support and expertise. Key learning points include:
- Historical blood groups must never be used for RBC transfusion requests, because, if the records are wrong, ABO-incompatible RBC may be transfused that threaten the patient's life.
- Timely medical consultation is critical for a variety of situations involving deviations in testing, the selection of blood components, and for alert values and alert situations.
- Dispensary-only and other satellite facilities should have a list of critical values (alert values and situations) that require immediate consultation.
- Requesting TM consultation should be strongly encouraged in all facilities, but especially in small facilities where technical and clinical staff may have limited TM expertise.
- Each TS must have a medical director, who is ultimately responsible for all medical and technical policies and procedures, including those in satellite facilities.
- Training and competency assessment are required by blood safety standards as part of a quality system that protects patient safety and requirements extend to satellite facilities.
This quiz is offered as a self assessment.
1. What are some of the benefits of patient records when pretransfusion testing?
2. What are some of the precautions related to using records in the TS?
3. Blood can be returned to inventory or reissued if they have been at room temperature or in an uncontrolled environment for no longer than:
- 30 minutes
- 1 hour
- 4 hours
- 24 hours
4. In a TS who is ultimately responsible for all technical and medical policies and procedures?
5. What are alert values or situations and why are they significant to staff in small facilities?
6. Who is responsible for ensuring that required technical and medical expertise is available within a TS satellite facility?
7. Is it only technical staff that need to be trained and undergo competency assessment in a TS?
8. Which types of knowledge and skills should competency assessment programs assess?
9. When it is essential to obtain medical consultation in the TS? Provide examples that are required by blood safety regulations and some that are best practice, even if not mandated.
10. List several blood safety standards related to training and competency assessment in the TS.
AuBuchon JP. The role of transfusion medicine physicians. A vanishing breed? Arch Pathol Lab Med 1999; 123(8): 663?7.
Boulton F. The ?hospital transfusion practitioner". Blood Matters 2002 May.
Brecher ME, Hay SN. Bacterial contamination of blood components. Clin Microbiol Rev 2005 Jan; 18(1):195?204.
Feenstra S. Role of a transfusion nurse. Blood Matters 2003 July;5(3):1?3.
Kuehnert MJ, Roth VR, Haley NR, Gregory KR, Elder KV, Schreiber GB, et al. Transfusion-transmitted bacterial infection in the United States, 1998 through 2000. Transfusion 2001 Dec;41(12):1493?9.
Lumadue JA, JS Boyd, and PM Ness. Adherence to a strict specimen-labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens. Transfusion. 1997;37:1169?72.
Shulman IA, Jones FS. Practical aspects of the self-assessment of the issue and administration of blood: a review of two hospitals' experiences. Am J Clin Pathol 1997 Apr;107(4 Suppl 1):S17?22.
Williamson LM, Lowe S, Love EM, Cohen H, Soldan K, McClelland DB, et al. Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports. Br Med J 1999;319:16?9.
(also see individual discussion sections)
Australian Govt. Towards better, safer blood transfusion? A report for the Australian Council for Safety and Quality in Health Care, Commonwealth of Australia 2005. (Excellent information, including much about Canada, the UK, and more)
BC Provincial Blood Coordinating Office:PBCO
CBBS e-Network Forum: Compatibility testing for issuing non-rbc components(Dec. 13, 2000).
CBBS e-Network Forum: Reporting of critical values by transfusion service laboratories. (Aug. 2005)
College of Physicians & Surgeons of Alberta. ALQEP TM program guide
CSA. Blood and blood components (Z902-04). Mississauga, Ontario Canadian Standards Association, 2004.
Hamilton QUEST. Sharing our Strategies (SOS) Manual
Ontario Nurse Transfusion Coordinators: ONTraC
Scottish National Blood Transfusion Service (SNBTS). Quality improvement programme: safe and effective transfusion in Scottish hospitals ? the role of the transfusion nurse specialist (SAET Study). April 2004
SNBTS. Better Blood Transfusion
TraQ clearinghouse: Technology to enhance safety