Author details

Julia C. Tolentino<sup>1</sup> , Jenny Schadt<sup>3</sup> , Benjamin Bird<sup>2</sup> , Franz S. Yanagawa4 , Thomas B. Zanders<sup>5</sup> and Stanislaw P. Stawicki<sup>6</sup> \*

\*Address all correspondence to: stawicki.ace@gmail.com

1 Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA

2 St. Joseph University, Philadelphia, PA, USA

3 Temple/St. Luke's Medical School, St. Luke's University Health Network, Bethlehem, PA, USA

4 Department of Surgery, Warren Hospital, St. Luke's University Health Network, Phillipsburg, NJ, USA

5 Department of Medicine, Section of Pulmonology and Critical Care, St. Luke's University Health Network, Bethlehem, PA, USA

6 Department of Research & Innovation, St. Luke's University Health Network, Bethlehem, PA, USA

#### References

Medical personnel should communicate with the family before the transport about the projected time, duration, destination, and expected benefit or outcome of the process. Thus, proper expectations can be met, and family members are provided with basic goals and parameters regarding the overall clinical context [86]. Prior to the transport, the patient's proxy or next of kin should be available, and their phone numbers should be obtained by the transport team in case of unexpected events, especially if the patient is not decisionally competent or becomes noncompetent during the transport or procedure. When the patient is stabilized at the destination or returned to the ICU, the patient's proxy and family members should be informed and updated on the

Intrahospital transfers are among some of the most dangerous, yet necessary endeavors that hospitalized patients require during the implementation of diagnostic and therapeutic plans. Although the overall risk profile of IHTs depends on patient acuity, other factors are important risk determinants as well, including location and distance between hospital departments, team member knowledge and communication, the complexity of medical management, and the equipment involved. Significant amount of provider/staff training is required to optimize the team performance and minimize the overall risk of an adverse event occurring during an IHT. Healthcare professionals are encouraged to strictly follow the fundamentals of patient safety, as outlined throughout the Vignettes in Patient Safety cycle, to help reduce complications and to

patient's condition by a member of the transport team [86–88].

propagate a culture of safety throughout their clinics and hospitals.

, Benjamin Bird<sup>2</sup>

1 Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA

4 Department of Surgery, Warren Hospital, St. Luke's University Health Network,

3 Temple/St. Luke's Medical School, St. Luke's University Health Network, Bethlehem, PA,

5 Department of Medicine, Section of Pulmonology and Critical Care, St. Luke's University

6 Department of Research & Innovation, St. Luke's University Health Network, Bethlehem,

, Franz S. Yanagawa4

, Thomas B. Zanders<sup>5</sup>

, Jenny Schadt<sup>3</sup>

2 St. Joseph University, Philadelphia, PA, USA

Health Network, Bethlehem, PA, USA

\*

\*Address all correspondence to: stawicki.ace@gmail.com

15. Conclusions

118 Vignettes in Patient Safety - Volume 3

Author details

Julia C. Tolentino<sup>1</sup>

USA

PA, USA

and Stanislaw P. Stawicki<sup>6</sup>

Phillipsburg, NJ, USA


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**Chapter 8**

**Provisional chapter**

**Transfusion Error in the Gynecology Patient: A Case**

**Transfusion Error in the Gynecology Patient: A Case** 

Emergency blood transfusion (EBT) is a life-saving intervention which also carries a significant risk of harm in the event of a transfusion reaction. Our chapter starts with a hypothetical case study of a gynecology patient who underwent emergent hysterectomy with severe hemorrhage managed with an emergency blood transfusion. During the aggressive resuscitation, the patient was inadvertently transfused with blood products that had been allocated for another patient. Through this clinical vignette, we review the operational aspects of an EBT and identify sources of transfusion-related errors. We emphasize best practices that can be implemented with the goal of improved patient

safety. This chapter offers a concise, practical review of EBT for our readers.

**Keywords:** transfusion error, massive transfusion protocol, postpartum hemorrhage

Transfusion medicine is used to manage the bleeding patient. An emergency blood transfusion (EBT) protocol describes how a massive blood transfusion (MBT) can be performed in an effort to compensate for the blood loss of a severe hemorrhage. Not every EBT is an MBT: in a patient with a low cardiopulmonary reserve, moderate blood loss can require an EBT but not the volume of an MBT. Near miss and sentinel events in the hospital setting continue to represent a significant concern for patient safety [1]. In the context of blood transfusions, a "near miss" event includes any error that could cause administration of an incorrect blood product but is recognized prior to the start of transfusion. Failure to recognize the error can result in the sentinel event of acute hemolytic transfusion reaction (AHTR) due to major blood

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.79184

**Review with Analysis**

**Review with Analysis**

E.L. Dierking

E.L. Dierking

**Abstract**

**1. Introduction**

Carly Madison Hornis, R.S. Vigh, J.F. Zabo and

Carly Madison Hornis, R.S. Vigh, J.F. Zabo and

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79184


#### **Transfusion Error in the Gynecology Patient: A Case Review with Analysis Transfusion Error in the Gynecology Patient: A Case Review with Analysis**

DOI: 10.5772/intechopen.79184

Carly Madison Hornis, R.S. Vigh, J.F. Zabo and E.L. Dierking Carly Madison Hornis, R.S. Vigh, J.F. Zabo and E.L. Dierking

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79184

#### **Abstract**

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1992;79(4):240-243

tional study. Neurocritical Care. 2013;18(3):298-304

Emergency blood transfusion (EBT) is a life-saving intervention which also carries a significant risk of harm in the event of a transfusion reaction. Our chapter starts with a hypothetical case study of a gynecology patient who underwent emergent hysterectomy with severe hemorrhage managed with an emergency blood transfusion. During the aggressive resuscitation, the patient was inadvertently transfused with blood products that had been allocated for another patient. Through this clinical vignette, we review the operational aspects of an EBT and identify sources of transfusion-related errors. We emphasize best practices that can be implemented with the goal of improved patient safety. This chapter offers a concise, practical review of EBT for our readers.

**Keywords:** transfusion error, massive transfusion protocol, postpartum hemorrhage

#### **1. Introduction**

Transfusion medicine is used to manage the bleeding patient. An emergency blood transfusion (EBT) protocol describes how a massive blood transfusion (MBT) can be performed in an effort to compensate for the blood loss of a severe hemorrhage. Not every EBT is an MBT: in a patient with a low cardiopulmonary reserve, moderate blood loss can require an EBT but not the volume of an MBT. Near miss and sentinel events in the hospital setting continue to represent a significant concern for patient safety [1]. In the context of blood transfusions, a "near miss" event includes any error that could cause administration of an incorrect blood product but is recognized prior to the start of transfusion. Failure to recognize the error can result in the sentinel event of acute hemolytic transfusion reaction (AHTR) due to major blood

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

group incompatibility [2]. AHTR was a leading cause of transfusion-related mortality from 2005 to 2009, second only to transfusion-related acute lung injury (TRALI) [3].

time, a surgeon noted that the blood being transfused was not O negative blood. The anesthesiologist was alerted and he immediately stopped the transfusion. The circulating nurse called the blood bank to notify them of the error. The blood bank personnel had incorrectly assumed that the MBT was initiated for the patient who had tested positive for the antibodies. The operating room staff removed all blood products from the operating room, and new O negative noncross-matched blood was sent. By this time, the patient had developed a state of disseminated intravascular coagulation (DIC). With no identifiable active bleeding source, the patient's pelvic

Transfusion Error in the Gynecology Patient: A Case Review with Analysis

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127

cavity and vagina were packed, and she was transferred to the intensive care unit (ICU).

**3. Discussion**

hysterectomies [4].

the blood transfusion process.

The patient's ICU course included aggressive resuscitative efforts with multiple blood transfusions and ventilator support due to transfusion-related acute lung injury (TRALI). Once stable, the patient was taken back to the operating room for removal of packing and re-exploration where no active bleeding was noted. Fortunately, the patient recovered from her nearfatal injuries, and she was eventually discharged home with a close outpatient follow-up.

Hysterectomy is one of the most commonly performed surgical procedures in the United States. Symptomatic uterine fibroids are the leading indication for the procedure, accounting for 52% of this procedure. Abnormal uterine bleeding is the indication for another 42% of

Similarly, maternal hemorrhage is a leading cause of maternal morbidity and mortality worldwide. Its incidence varies widely but is thought to occur in 1–5% of all deliveries [5, 6]. This is a concerning fact since obstetric services are provided in 92% of rural hospitals [7]. These smaller hospitals do not have the same resources as their larger urban counterparts to handle severe hemorrhage from a variety of etiologies. For these smaller institutions, developing a standardized plan to manage emergencies such as postpartum hemorrhage is critical [7]. All surgical and emergency services should devise comprehensive approaches that identify, evaluate, treat, and monitor a hemorrhaging patient in order to stop bleeding at earlier stages, reduce the number of blood products transfused, and to reduce adverse outcomes [1]. The case review above demonstrates the need for an institution to establish and practice sound policies for the emergency preparation, transportation, and administration of blood products. Root cause analysis (RCA) is a process with the primary aim of identifying any factors that may influence the nature, magnitude, timing, and/or occurrence of an error, keeping in mind that more than one root cause can impact an event. Through such a methodical approach, RCA is commonly employed after an occurrence of an error in order to develop and implement preventative strategies to improve future response and outcomes. Through this chapter, we perform a root cause analysis to systematically identify "root causes" of potential errors in

Medical errors fall into one of two broad classes, errors of omission and errors of commission. An error of omission is one that occurs because an action was not taken, whereas an error of commission occurs because an incorrect action was taken [8]. The clinical vignette described

The blood administration process is challenging in a chaotic, often time-sensitive environment that employs high-volume blood transfusions to prevent a hemorrhaging patient from dying. This combination of factors creates a formidable risk to patient safety [1]. Optimal strategies have been developed to standardize the management of blood transfusions in the setting of a severe hemorrhage, irrespective of its etiology.

This chapter describes select best practices and identifies system vulnerabilities that may lead to near misses and sentinel events so as to improve patient outcomes and provide an errorfree delivery of blood products. We also review potential solutions that our institution has implemented to decrease the transfusion error risk associated with blood product administration. The case review subsequently underscores how imperative it is to identify the critical steps within the process of blood transfusions so as to prevent error.
