**7. Error tracking systems**

In addition to the use of fibrinogen-rich medications or cryoprecipitate, anti-fibrinolytics also play a role in EBT. Tranexamic acid can safely reduce the risk of death in both trauma and obstetric-related hemorrhage [28, 29]. The drug must be administered within 3 h of bleeding

Different solutions exist for bleeding while anticoagulated on warfarin. The prothrombin complex concentrate drug Kcentra (CSL Behring, King of Prussia, PA) can reverse coagulation factor deficiency induced by a vitamin K antagonist faster than fresh-frozen plasma [30]. Determining when to stop transfusing can also be challenging. An i-Stat device (Abbott Point of Care Inc., Princeton, NJ, USA) should be avoided if possible [31]. Evaluating the response to transfusion can be achieved via a serum hemoglobin value 15 min after transfusion. Other reassuring laboratory values include a platelet count greater than 50,000/μL, an international normalized ratio (INR) of less than 1.5, or a fibrinogen level greater than 100 mg/dL. Ultimately, the normalization of the patient's hemodynamic status in conjunction with visible signs of hemostasis should signal the medical provider to terminate the code crimson. Alternatively, the recognition of the futility of resuscitation should also be viewed as a terminal end point. Upon termination of the blood transfusion, unused blood products should be returned to the blood bank for refrigeration and storage. The blood products transported by runners or the PTS are continuously monitored thermally to ensure the integrity of returned, unused products.

EBT protocols facilitate the efficient ordering and transport of blood products for patients with moderate to severe hemorrhage. These protocols also ensure that an ongoing supply of blood products arrives at the patient's bedside until hemostatic control is achieved. Many hospitals have established an MTP. In obstetrics, 95% of hospitals with a postpartum hemorrhage protocol possess an MTP [32]. An MTP is traditionally defined as more than 10 units of

An MTP can be used to manage severe maternal hemorrhage and improve patient safety. In their study, Shields et al. showed a faster resolution of maternal bleeding, the use of fewer blood products, and a 60% decline in the rate of DIC with the use of MTP [33]. In addition, the establishment of an MTP protocol led to both physicians and nursing staff reporting improved

Health-care providers have varying experience levels in dealing with EBT and MBT. The relatively low frequency with which MBT is encountered limits the accumulation of experience with severe hemorrhage. This suggests that standardized interventions are critical in order to achieve an optimal outcome. One way to gain experience and familiarity with standardized

Simulation is used to train and familiarize providers with how to respond to emergency situations. By using team approaches to problem solving and utilizing root cause analysis, patient

clinical knowledge and comfort level with responding to significant bleeding events.

onset. It is associated with a minimal adverse event rate [28].

134 Vignettes in Patient Safety - Volume 3

**5. Benefits of emergency blood transfusion protocols**

pRBCs in 24 h or more than four units of pRBCs in 1 h.

EBT protocols is through simulation.

**6. Benefits of simulation**

Though uncommon, transfusion-associated adverse events can occur in the emergency setting. In response, programs have been established that track these events. The goals of these programs are to ultimately improve patient safety by minimizing the morbidity and mortality of transfusion procedures. The programs also serve to identify emerging complications, including errors and near misses, as well as pathogens associated with blood transfusion. One such surveillance protocol is the National Healthcare Safety Network Biovigilance Component Hemovigilance (NHSN HV) module [38]. This module can be used by any US health-care facility where blood components and products are transfused. Participation requires a comprehensive surveillance of patients and blood components throughout the transfusion process, from product receipt until patient administration. In addition, the reporting of all adverse transfusion reactions and associated incidents that occur for patients transfused at the studied facility is required. By participating in the module, health-care facilities can use data entered into the National Healthcare Safety Network to monitor adverse reactions and events. This allows for better identification of areas requiring intervention and to modify prevention strategies that reflect the specific needs of a particular health-care facility.
