1. Document the Event
- Adverse Event form intitiated
2. Investigate
- Transfusion Reaction Workup performed.
- Administrative Review conducted. Classification determined to be Near Miss with no harm to patient.
- Severity/Probability - SAC score 2 (potential to be major/remote)
- Immediate actions - Monitor patient for possible delayed reaction
3. Root Cause Analysis - Required
Tools Used:
- Process Flow Diagram
- Cause and Effect Diagram
Root cause/contributing factors identified:
- An error in the lab information system blood bank module truth tables caused the system to fail to alert about the incompatibility of the product.
- Distractions, interruptions, and preoccupation with other stats decreased the likelihood of the technologist recognizing an error.
- The blood transfusion policy was not clear about type compatibility of plasma products, leading the nurses not to question or clarify the difference in product type and patient blood type.
4. Develop Action Plan
- Correct the Blood Bank module Truth Table and validate the change
- Create a multidisciplinary work group to design ways to reduce interruptions and create a "Quiet Zone" in Blood Bank
- Revise blood administration policy to clarify and include charts of compatible types for plasma and red cells
- Revise nursing skill validation to reflect changes to policy
5. Implement Action Plan
- Case presented at Transfusion Committee meeting
- Report to the Joint Commission
- Assign responsibilities and timelines
6. Evaluate Effectiveness of Actions
- Track Blood Bank order errors for the next six months, with a goal to decrease by 50%
