Wrong Blood Transfusion from Autologous Salvaged Blood
By Luc Puis
Blood from the cell saver. You can’t go wrong with that, right? Process it, label it, keep it in the operating room and administer it to a single patient in the operating room.
Sometimes, things can go wrong, even with autologous cell-saver blood. And like is the case most of the time with medical mistakes: it’s not a single error that is the cause of an event, but a collection of “violations of procedures, haphazard organizational policies, poor communication, workload and staffing deficiencies, human factors and cultural challenges.” (Uramatsu M, 2022).
As the seminal report “To Err is Human” stated in 2000, the problem is not bad people in healthcare – it is that good people are working in bad systems (Kohn LT, 2000).
The Findings
While the case report describes the event itself, a postoperative ICU patient was given a bag of autologous blood from a different patient, operated on the day before; what happened afterward is the most important and interesting part of the case report. The patient survived, and although they had a more eventful postoperative course due to the event, it could have been easily covered up, and no one would probably have known that the event had occurred. But instead, not only did the surgeon and the hospital disclose the event and apologize to the family twice, but they also investigated the event to search for the cause with a method called Root Cause Analysis (RCA).
While it is beyond the scope of this article to go deeper into the methodology of RCA, the main findings are fascinating and exemplary for many events happening daily in our practice.
Yes, the cause for the adverse blood transfusion was a nurse not checking the blood bag before donation, but the reason they did that was another nurse picking the wrong blood bag out of the fridge, and the reason for that was … And so on, and so on. In a stepwise fashion, all the steps that led to the event are looked back upon, and, in the end, a multitude of factors were responsible for the error. Not just the nurse donating the bag.
The committee investigating the event found that the lead root cause for the event was:
“Intraoperative salvaged blood, without starting to administer the blood before leaving the theatre, and bringing the bag to the ICU.”
System Errors Can Happen
It is often so in healthcare that we think: this event was utterly preventable. But yet, they still happen.
So next time you see something similar or hear about something that has happened, don’t be too quick to judge the people involved. One day, you might be a victim of the poorly designed system. Or, if you were involved in such an event, use the algorithm described in this case report to see whether anything can be changed in the system to prevent the error from happening again.
After all, one of the recommendations of the IOM report of 2000 was that there should be more systems installed so we can learn from our mistakes.
Be safe out there!
Sources
Uramatsu M, Maeda H, Mishima S et al. Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. J Cardiothorac Surg. 2022; 17(1): 182
Kohn LT, Corrigan JM, Donaldson MS (eds.) Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000.
