Overnight Transfusions

Submitted by Christopher Corkery, NZ Blood Service Nurse Specialist, Waikato. Originally printed in June 2006 IVNNZ Inc. Newsletter

There is always a great deal of public attention when errors in health care are highlighted, and rightly so. The stake holders in health care expect high standards from their health professionals. Opinions from the Health and Disability Commissioner are often taken up by media and interested political groups in a way that doesn't necessarily assist in getting to the root cause of a problem. However, when such errors occur, doctors, nurses and managers need to examine their personal practices and the systems in their institutions with the aim of reducing such errors.

It has been estimated that in the United States approximately 7000 deaths occur each year due to medication errors.1 The head count may not be as high in New Zealand but we have a similar medication error rate to other western countries.2 An initial step in reducing the number of deaths is to examine and identify relationships between errors, their causes and possible solutions. It would come as no surprise that some studies have shown that physicians make more medication prescribing errors overnight than at other times of the day.3 The Serious Hazards of Transfusion (SHOT) report which is a UK based transfusion error reporting system has also emphasises the risk that more errors occur with overnight transfusions.4

Logic would suggest that overnight transfusions may not always be in the interests of the patient if they are "routine top-up" transfusions. Blood transfusions regardless of the time of day that they are administered, require a minimum number of clinical observations. If the transfusion occurs at night the observations may well disrupt the sleep of the patient and probably the neighbouring patient, unless your hospital has the luxury of single rooms. In darkened rooms the detection of an adverse reaction may be missed, and, often at night, many wards run on a skeleton staff which may compromise adequate monitoring of patients receiving transfusions.

Case Study

A patient had been prescribed a red cell transfusion and the unit of blood had arrived on the ward and two of the night staff nurses proceeded to check the unit. This was done at the nurse's station so as not to disturb the other patients in the room. At completion of checking, a patient started calling out and both nurses went to answer the patient's call. While the nurses were away another unit of blood was delivered to the ward by a hospital attendant and left on the bench in the nurse's station. One nurse returned to the nurse's station and picked up the unit of blood, not noticing that there was another unit there. The nurse proceeded to connect the blood to the intravenous set of the patient for whom she checked the details prior. Baseline observations were done, and, as the patient was familiar to the staff nurse no bedside identification checks were performed before the transfusion was commenced. The second nurse returned to the nurse's station and noticed the unit of blood for the patient was still there and decided to investigate what her colleague was doing. At this point the error was noted and the transfusion was stopped. The patient was unharmed. The nurses notified the hospital quality management system and the incident was investigated.

It was discovered that there were no hospital policies or procedures referring to the delivery of units of blood to wards or to bed-side checking procedure or routine over-night transfusions. The hospital used this episode as an educational opportunity. Attendants delivering blood to wards now have to hand the unit to a staff nurse preferably to the nurse responsible for the patient. It was emphasised that the bed-side checking procedure was to be performed at the bedside regardless of the time of day and whether the staff nurse was familiar with the patient or not. A policy of discouraging routine over-night transfusions was also implemented.

An audit performed by the New Zealand Blood Service in 2004 in several main centres in New Zealand demonstrated that although the majority of patients were monitored appropriately, 15% (n=49) of the transfusions were clinically inappropriately transfused at night.5 An inappropriate transfusion was defined as occurring when the patient was asymptomatic and/or the transfusion could have been delayed to the following morning and/or the patient was not in a high dependency area (e.g. ICU). The number of inappropriate units ranged from 6.2% to 22.2% depending upon the centre.

It would have been unlikely for such a small audit to detect any adverse reactions amongst recipients, but an inappropriate overnight transfusion potentially puts the patient at increased risk. It also can disturb sleep patterns of the transfused patients as well as others and creates unnecessary work for nursing and medical night staff. If your patient has been prescribed a transfusion it is good practice is to ensure that the transfusion occurs in a safe environment and this includes avoiding unnecessary overnight transfusions.

References

1. Kohn, L., Corrigan, J. & Donaldson, M. (1999) To err is human: Building a Safer Health System. (1st Ed) Institute of Medicine. Washington. National Academy Press
2. Davis, P., Lay-Yee, R., Briant, R., Ali, W., Scott, A. & Schug, S. (2003) Adverse events in New Zealand public hospitals I I : preventability and clinical context. The New Zealand Medical Journal. Vol 116. 1183.
3. Gregory, W.H., Bradley, E.B. & Soliz, T. (2005) Overnight and Postcall errors in medication orders. Academic Emergency Medicine. July, Vol 12.7, 629-634.
4. Serious Hazards of Transfusion (SHOT) UK 2003. www.shotuk.org.uk
5. Rishworth, S. & Hammond, C. (2004) Overnight transfusion audit within five centres in New Zealand. Unpublished New Zealand Blood Service Audit Report