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- Case Study O6 deals with a transfusion reaction following red cell transfusion that coincidentally involved a nurse following a physician's orders even though they were contraindicated by hospital policies and procedures. The provocative case title is meant to enhance interest.
- This case was based on a study case used to teach nurses at the McGill University Health Centre (MUHC) in Montréal, Québec.
- TraQ has revised the case and added enhancements (discussion sections, self study questions, quiz) and has copyright for this web-based case.
- Case O-6 is the sixth in the "Other cases" series (cases or reports initially developed or published elsewhere). The original case forms the starting point for the TraQ case.
- Like all "Other cases" Case O6 focuses on best practices and standards related to the case, for example:
- Monitoring patients being transfused
- Iinvestigating adverse events
- Importance of critical thinking when confronted by problems
- Responsibilities of health professionals to protect patient safety as related to scope of practice and interaction with other practitioners
Upon completion of this exercise, participants should be able to do the following:
- Discuss standards and best practices related to monitoring patients before, during, and after transfusion.
- Discuss best practices for investigating a suspected transfusion reaction.
- Explain the responsibilities of health professionals for patient safety as it relates to their scope of practice and other health providers.
- Discuss perceived loss of professional autonomy as an obstacle to collaboration and open questioning within health teams.
- Describe mechanisms that can allow members of different professions to question inappropriate orders and decisions of other health providers in a collaborative environment.
- Discuss education to assure that health providers have the necessary skills to provide expected interdisciplinary checks for patient safety, such as questioning physician orders.
This case derives from an unpublished study case created by Amélie Rivard, Nurse Clinician in charge of Transfusion Safety, McGill University Health Center. Amélie and her colleague Anna Urbanek work as Nurse Clinicians in charge of Transfusion Safety at MUHC. Amélie Rivard retains copyright for the original case.
TraQ has copyright for this web-based case, which has been fictionalized to enhance its educational value. The described events and practices did not happen at MUHC.
Special thanks to the following who kindly provided advice, information, and ideas for the case. The discussion benefits from their valuable input (errors or misstatements are entirely those of the author):
- Gwen Clarke, MD FRCPC (Capital Health, University of Alberta, & Canadian Blood Services, Edmonton, AB)
- Denise Evanovitch, MLT, Dipl. Adult Ed (Technical Specialist, Education and Training, Hamilton Regional Laboratory Medicine Program, Hamilton, ON)
- Kate Gagliardi, BA, ART (Regional Blood Coordinator, Ontario Regional Blood Coordinating Network, Hamilton, ON)
- Ana Lima, RN, HP (ASCP) (Transfusion Safety Nurse, Sunnybrook Health Sciences Centre, Toronto, ON)
- Veronika Pulley, RN (Blood Conservation Program Coordinator [ONTraC], Windsor Regional Hospital, Windsor, ON)
- Amélie Rivard, RN (Transfusion Safety Nurse, McGill University Health Centre, Montreal, PQ)
The essentials of the case: (Hover mouse over wordsto expand to a definition)
A 26 year old single female living with her parents was admitted for a CSF leak from the nose, fever, lethargy, neck stiffness and pain. She had multiple surgeries in the past and her health status was poorly controlled. She was admitted to the ER on Jan. 9 for brain surgery. A diagnosis of meningitis followed within a few days.
On Jan. 12 a CT scan of the head showed a large amount of intracranial air in the subarachnoid space and ventricular system. There was a moderate hydrocephalus and the size of the ventricular system had progressed. Between the Jan.1213 a drain was inserted via a frontal burr hole, the tip of the drain located in the third ventricule. On the following CT scan the volume of intracranial air had slowly decreased and the size of ventricular system was reduced. The morning of Jan. 19 the physician decided to close the drain and the patient stabilized.
In the afternoon of Jan. 19 patient hemoglobin was dropping quickly and the physician decided to transfuse 2 units of packed red blood cells (PRBC).
Blood Test Results (Reference Range)
Hemoglobin 79 g/L (120?160)
Hematocrit 0.270 L/L (0.370?0.470)
Platelets 503 x 109/L (140?440 x 109/L)
Past Medical History
- (bilateral resection and radiotherapy)
- (chemotherapy in 2005)
- Nasal and sinus surgery
- Port-o-cath insertion (
Transfusion Service Laboratory
The patient had been tested once before in another hospital as O Rh positive. A type and screen was done, 2 units of packed red blood cells (PRBC) were crossmatched, and one was sent to the patient's ward.
Transfusion - PRBC #1
The first unit was started at 10:55 am. Vital signs were recorded:
- Blood pressure: 130/72
- Oxygen saturation: 96%
- Temperature: 36.9oC
- Pulse: 109/min.
As the nurse was unable to get an infusion rate faster than 1 drop/10sec., she flushed the port-o-cath with 350 U of heparin. The rate did not increase and she replaced the needle with no success. Finding a new IV access was unlikely because patient had poor vein access and would have required a new port-o-cath insertion or a central venous access, not considered possible as the patient was already unstable.
The nurse called the attending physician to explain the situation and charted the conversation as follows:
- Dr. Brown was made aware; he ordered to continue transfusion even if it takes all day
The nurse followed the order and ran the transfusion over a little more than 8 hours. No further vital signs were taken.
Transfusion - PRBC #2
The second unit was started by the same nurse (who was working a 12-hour shift) at 19:15 h. Vital signs were taken with no untoward results. No further vital signs were taken until 20:30 h. when the patient started shaking and stiffness was noted. The transfusion was stopped, the physician was contacted, and the nurse followed standard procedures detailed in the facility's nursing manual.
Vital signs were
- Temperature: 40.9 oC ( )
- Pulse: 220/min.
- Blood pressure: 150/99
- Oxygen saturation: 98% on rebreather
The patient presented but no , no bronchospasm, but loss of consciousness. The patient was given Benadryl IV, bolus 250cc and solumedrol IV push. The patient was then transferred to an intensive care unit.
In the ICU, patient was covered with cooling blanket and received Lopressor x 4 doses, Fentanyl push, Propofol, Dilantin, IVIg boluses, Tylenol. The patient was finally intubated and put into artificial coma. Blood culture was done and blood bag returned to blood bank for investigation.
Upon detecting the suspected transfusion reaction, the transfusion service (TS) was contacted and the TS performed a transfusion reaction investigation according to its policy and procedure manual, eliminating a hemolytic transfusion reaction as the cause.
Because a bacteriogenic reaction was suspected due to fever subsequent to a prolonged transfusion time (8 hrs.+), the hospital microbiology laboratory performed gram stains and cultures of both PRBC contents, as well as recipient blood cultures. All were negative.
Subsequent analysis revealed that the nurse in question required remedial training related to resolving slow running transfusions and critical thinking in general, and also required re-training for how to monitor and document transfusions.
A more systemic problem was identified regarding the responsibilities and related skills of health professionals to provide checks for patient safety as part of the healthcare team. In-service interdisciplinary educational sessions were held to discuss and resolve the issues.
Questions to be Considered
To test your knowledge and as an advance organizer for the discussion section, read and consider these questions:
- What types of transfusion reactions are possible in this scenario of fever following transfusion?
- Can a transfusion be given over more than 4 hours if a physician orders it?
- What can you do if a physician's order contradicts a policy or procedure?
- What could the nurse have done after she saw that the port-o-cath was not running properly?
- What patient consequences could happen if nurses do not properly chart a transfusion and take vital signs for the entire transfusion and a blood component culture is found to be positive?
Proceed to Discussion (includes interactive questions with feedback):
This case study presents a scenario in which a nurse did not follow several key transfusion protocols and procedures, including adhering to the time limit for transfusing blood, monitoring vital signs throughout a transfusion, and questioning orders that contradicted hospital policies and procedures.
Based on laboratory results and a multidisciplinary discussion, staff concluded that a febrile non-hemolytic reaction had likely occurred after the second PRBC and had triggered subsequent events:
- Increased temperature and chills increased intracranial pressure (the drain had been closed the previous day), leading to
- Seizure and convulsions (treated by medication, induced coma, and intubation)
Further analysis resulted in individual re-training and a system-wide education program on responsibilities and skills for providing interdisciplinary checks to ensure patient safety.
Key learning points include:
- Clinical staff who administer transfusions must be trained and assessed in blood administration.
- Monitoring and documenting vital signs must be done for each blood component transfused before, during, and after transfusion according to established policies and procedures.
- Scopes of practice ensure that health professionals have the required education, training, and professional qualifications to perform their duties competently and safely.
- Within their respective scopes of practice, members of the health care team collaborate in providing patient care.
- Perceived loss of autonomy is considered to be a major obstacle to collaboration and open questioning within health teams.
- Nurses and allied health care professionals such as medical laboratory technologists have a duty to question physician orders that are inappropriate or unclear.
Brunskill S, Doree C, A. Blest A, J. Murdock J, M. Roberts M, and D. Watson D. Bedside practice of blood transfusion - Where is the evidence? (poster P17) Transfus Med October 2006 Oct;16(s1):32.
Carroll JS, Quijada MA. Redirecting traditional professional values to support safety: changing organisational culture in health care. Qual Saf Health Care 2004 Dec;13 Suppl 2:ii16?21.
Davies C. Getting doctors and nurses to work togetherBMJ 2000 Apr 15;320:1021?2.
Hillyer CD, Josephson CD, Blajchman MA, Vostal JG, Epstein JS, Goodman JL. Bacterial contamination of blood components: risks, strategies, and regulation: joint ASH and AABB educational session in transfusion medicine. Hematology Am Soc Hematol Educ Program. 2003;575?89.
Kleinman S, Chan P, Robillard P. Risks associated with transfusion of cellular blood components in Canada. Transfus Med Rev. 2003 Apr;17(2):120?62.
Mancini ME. Performance improvement in transfusion medicine. What do nurses need and want? Arch Pathol Lab Med 1999;123(6):496?502.
Moore SB, Mary L. Foss ML. Error management: theory and application in transfusion medicine at a tertiary-care institution. Arch Pathol Lab Med 2003;127(11):1517?22.
Salvage J, Smith R. Doctors and nurses: doing it differently. The time is ripe for a major reconstruction. BMJ. 2000 April 15; 320(7241): 1019?20.
Shulman IA, Saxena S, Ramer L. Assessing blood administering practices. Arch Pathol Lab Med 1999;123(7):595?8.
Silva MA, Gregory KR, Carr-Greer MA, Holmberg JA, Kuehnert MJ, Brecher ME; Task Force. Summary of the AABB Interorganizational Task Force on Bacterial Contamination of Platelets: Fall 2004 impact survey.Transfusion. 2006 Apr;46(4):636?41.
Williams PM. Techniques for root cause analysis. Proc (Bayl Univ Med Cent). 2001 April; 14(2): 154?7.
(also see individual discussion sections)
Agency for Healthcare Research and Quality.One dose, 50 pills (Morbidity and Mortality Rounds on the Web)
Altogether for Health(editorial, Student BMJ, Jan. 2006)
BCSH.The administration of blood and blood components and the management of transfused patients (1999)
Bloody Easy Online Courses (Sunnybrook & Women's College HSC, Toronto, Ontario, Canada)
Calgary Laboratory Services. Policies relating to transfusion of blood components and products
Case 108 - Transfusion reaction (University of Pittsburgh)
CBBS e-Network Forum
Canadian Blood Services:
Collaborative care receives stamp of approval in CMA, CNA study involving HIV/AIDS (CMAJ 1996;154: 21?7)
Collaborative care means collaborative training (Health Council of Canada)
Disruptive Clinician Behavior: A Persistent Threat to Patient Safety (July /August 2006, Patient Safety & Quality Healthcare)
Interprofessional collaboration (CNA position statement)
Creating a culture for interdisciplinary collaborative professional practice
INTD 410 (University of Alberta, Edmonton, Canada)
Malpractice. In: Gale Encyclopedia of Nursing and Allied Health
Perlow D, Perlow M. Courts' perceptions of the responsibilities of nursing practice
Public Health Agency of Canada. User's Manual. Canadian Transfusion Adverse Event Reporting Form (April 2004) | More...
Royal College of Physicians and Surgeons of Canada (RCPSC):
Scope of practice:
UK: 2004 SHOT Report
The National Blood Authority (NBA) is currently working on a range of activities to support hospital and pathology services to fully implement the National Safety and Quality Standard for Blood and Blood Products. One of the ways in which this is being achieved is to identify areas of best practice already in existence across the country, record and document these practices for others to view and further develop in their own workplace. Relevant techniques, tools and approaches undertaken by various providers will be published below as they become available so other centres across Australia can adopt and modify practices to suit their own conditions. It is important to note that these case studies are provided as one example of an approach that worked for the individual facility. Where centres would like to adapt practices for local use, they should consider all implications and risks that may be specific to their own conditions prior to implementation.
Small volume tubes at Flinders Medical Centre, SA
Hospital acquired anaemia or iatrogenic anaemia is anaemia that results from blood loss due to repeated blood sample collection (phlebotomy), of hospitalised patients for the purpose of diagnostic testing. This case study illustrates the implementation of the introduction of small volume sample tubes at the Flinders Medical Centre intensive care unit, which significantly reduced iatrogenic blood loss due to diagnostic testing without adversely affecting the laboratory workflow.
Visit the Use of small volume tubes to reduce blood loss Case Study to see how this project was implemented.
Pathology Queensland comprises a hierarchical, networked system of 33 laboratories, providing pathology services to all Queensland Health public hospitals. This case study looks at the Pathology Queensland laboratories in the Royal Brisbane & Women’s, Redcliffe, Toowoomba and Townsville hospitals and illustrates some of the processes they have in place for blood management to minimise blood wastage, particularly around transfer arrangements and stock movement.
Visit Pathology Queensland Case Study for more information on these processes and the outcomes they deliver.
Hunter Area Pathology Service (HAPS), NSW
The Hunter Area Pathology Service operating at the John Hunter Hospital laboratory has one of the lowest wastage rates for blood and blood products in Australia. It is their close management of inventory, quick release of product upon request, a team of involved haematologists and close management of age of product inventory that enables the team at John Hunter Hospital to consistently achieve these low wastage rates as well as be forerunners in the field of inventory management.
Visit Hunter Area Pathology Service Case Study to see how HAPS is delivering better services to their community.
SAN Pathology, NSW
San Pathology at Sydney Adventist Hospital has one of the lowest blood and blood product wastage rates of the Australian private health sector. San Pathology's practices of limiting cross matches to 24 hours, a focus on individual responsibility, close haematology support, ongoing training and regular audits allow them to achieve and maintain an excellent discard rate. In addition it is clear that their culture and attitude towards treating blood as a precious resource has made a clear impact on the responsibility accepted by staff.
Visit SAN Pathology Case Study to see how the SAN is delivering better services to their community.
The Country Health South Australia Local Health Network (CHSA) BloodMove Project is a collaborative program to facilitate best practice in blood management throughout regional South Australia. BloodMove oversees 60 regional hospitals that are supplied with blood and blood products by both regional and metropolitan transfusion services. Since its commencement, BloodMove has sustained and further improved upon reduction of avoidable blood wastage in CHSA - from 15% in July 2007 to less than 1% in January 2013.
Visit BloodMove Project Case Study to see how this project has made substantial changes in South Australia.
BloodMove Platelets, SA
The BloodMove Platelets project aimed to reduce platelet wastage rates due to expiry. The project involves a collaborative platelet inventory concept comprising of moving Day 4 platelet blood stocks from low usage sites to high usage sites and then sharing a common multi-site near expiry Day 5 platelet inventory. With this collaboration and minor inventory level and dispatch practices changes, platelet wastage rates have reduced from highs of up 21% down to 6%.
Visit BloodMove Platelets Case Study to see how this project has made substantial changes in South Australia.
Burnside War Memorial Hospital, SA
Burnside War Memorial Hospital in South Australia recently reviewed its perioperative red blood cell ordering practices. The resulting implemented changes have allowed this not-for-profit community-based hospital to successfully reduce blood bag handling, improve patient safety and free up nurses for patient care. In addition, Burnside Hospital is well on its way to meeting Standard 7 of the National Safety and Quality Health Service Standards.
Visit Burnside War Memorial Hospital Case Study to see how this project was implemented.
The Royal Children's Hospital Melbourne Extended Life Plasma Protocol
The Royal Children’s Hospital, Melbourne introduced the use of Extended Life Plasma following extensive in-house safety and efficacy testing. As a result of implementing an ELP protocol, the laboratory at the Royal Children’s Hospital can not only provide thawed plasma in a timely manner but has also significantly reduced the wastage of unused thawed fresh frozen plasma across all clinical areas.
Visit The Royal Children’s Hospital Extended Life Plasma Case Study to see how this protocol was implemented.
Preoperative anaemia identification, assessment and management case study
The preoperative anaemia identification, assessment and management case study is intended to inform healthcare practitioners, health educators, health service managers and policy makers about preoperative anaemia screening. This resource provides a wealth of ideas and links to help hospitals use clinical practice improvement methods to implement an anaemia screening clinic based on evidence-based recommendations in the Patient Blood Management Guidelines: Module 2 – Perioperative.
Visit the Preoperative Anaemia Identification, Assessment and Management Case Study to see how this project was implemented.
Point of Care Coagulation Testing Case Study The Prince Charles Hospital Brisbane
This case study illustrates efforts undertaken by clinical staff at The Prince Charles Hospital in detecting, managing and monitoring critical bleeding in cardiac surgery patients through the use of Point of Care Coagulation Testing.
Visit the Point of Care Coagulation Testing Case Study The Prince Charles Hospital Brisbane to see how this project was implemented.
Liverpool Hospital, NSW
Prior to December 2013 Liverpool Hospital used a paper based sign-out register for logging blood products in and out of their operating theatre fridge. This register was often not completed or inaccurate. As a result staff could not be confident that unused red blood cells had been returned to the fridge within a 30 minute window thereby ensuring it was safe to reissue. There was also the additional risk that blood removed from the operating theatre fridge for transfusion could go to the wrong patient. These risks were seen as unacceptable and in an effort to reduce these risks, the hospital transfusion service implemented the use of Radio Frequency Identification (RFID) tags to track the intra-hospital movement of their blood and blood products with the aim of improving patient safety.
Visit the Liverpool Hospital Case Study to see how this project was implemented
Further Case Studies
The NBA is developing case studies on an ongoing basis. If you have a suggestion for either a general topic, or a specific example for a case study, please contact the Health Provider Engagement team at the National Blood Authority email support [at] blood.gov.au (subject: Case%20Studies) or by telephone 13 000 BLOOD (13 000 25663).
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