Blood Incompatibility

A New Look at Blood Transfusion: Evaluation of the risks and benefits prompts careful blood management
Joint Commission Perspectives on Patient Safety, Volume 7, Number 1, January 2007, pp. 1-12(12)

Blood transfusions were commonly regarded as unproblematic, but now researchers are finding that many transfusions are medically unnecessary and may actually put patients at risk. The potential risks of blood transfusions include immuno-suppression, the administration of incompatible blood, allergic reactions, and infections. In addition, growing blood supply shortages are endangering patients for whom transfusions are vital. This article provides strategies and tools to help health care organizations implement blood conservation techniques. BONUS ONLINE MATERIAL: An overview of studies that show the dangers of blood transfusions.

Using Failure Mode Effects and Criticality Analysis for High-Risk Processes at Three Community Hospitals
Joint Commission Journal on Quality and Patient Safety, Volume 31, Number 3, March 2005, pp. 132-140(9)

Background: The effect of an intensive glycemic management protocol was assessed in a heterogeneous population of critically ill adult patients. Methods: Patients representing 800 consecutive admissions following the institution of the protocol were compared with the 800 admissions immediately preceding the institution of the protocol in a 14-bed mixed medical-surgical intensive care unit (ICU). The protocol used intensive monitoring and treatment to maintain blood glucose values > 140 mg/dl. Continuous intravenous insulin was used if glucose values were > 200 mg/dl on two successive occasions. Results: Mean glucose decreased from 152.3 mg/dl to 130.7 mg/dl (p < .001), marked by a 56.3% reduction in the percentage of glucose values 200 mg/dl, without a significant change in hypoglycemia. There were decreases in the development of new renal insufficiency (p = .034) and in the number of patients receiving transfusion of packed red blood cells (p = .035) during the protocol period. Hospital mortality decreased 29.3% (p = .002), and ICU length of stay decreased 10.8% (p = .011) after institution of the protocol. Discussion: The 29.3% relative reduction in hospital mortality seen among the treatment patients following institution of the protocol probably exceeded the expectations of the initiative's champions. The culture of the ICU regarding glycemic control changed definitively. The protocol was extended to an intermediate care unit, resulting in improvement in glycemic control without an increase in hypoglycemia.

Root Causes: Tips for Avoiding Root Causes of Blood Transfusion Errors
Joint Commission Perspectives on Patient Safety, Volume 4, Number 1, January 2004 pp. 5-6(2)

Background: An applied research firm collaborated with staff at three community hospitals to apply Failure Mode Effects and Criticality Analysis (FMECA) to reduce the occurrence of adverse events associated with high-risk processes. The collaboration team, which developed its own FMECA approach, performed FMECAs for six processes, including prevention of patient falls, correct medication ordering and delivery of solid oral medication, and correct blood type transfusion for adult medical surgery patients. Development of FMECA Procedure and Tool: The hospitals followed eight specific steps to gather data, conduct FMECA sessions, and identify medical process weaknesses and risk reduction measures. Worksheets, including each step of the system process, success criteria, possible failure modes, causes of failure, frequency of failure, consequence of failure, and safeguards placed to avoid failure, were used to capture information during the FMECA sessions. Conclusions: On the basis of identified weaknesses, along with cost and other administrative considerations, medical process improvements were devised. Rules for devising improvements included improvements that help prevent the failure mode were better than those that mitigate the consequences, passive features that prevent failures were better than administrative controls, and improvements with the highest reliability were favored.