Case Study A. Incorrect administration of a blood product
This incident draws attention to checking procedure roles and responsibilities for blood products.
An 86 year old man was admitted with a fractured neck of femur, scheduled for surgery that afternoon. The patient’s international normalised ratio (INR) was elevated at 1.6, and the decision was made to treat this elevated level with a unit of fresh frozen plasma (FFP) prior to surgery. The medical officer (MO) went to the laboratory to collect the unit of FFP. On arrival the scientist pointed to where the FFP was located and requested the MO to sign the unit out of the laboratory in the blood register. The unit collected by the MO was allocated for another patient and labelling not yet completed. The MO signed the unit out against his patient details in the blood register without checking the product details matched. He then took the unit to the ward.
On return to the ward the MO handed the FFP to the nurse caring for the patient, who was unaware of the request for transfusion. The nurse noted the lack of paperwork accompanying the FFP and sent the patient services attendant (PSA), with the unit, back to the laboratory to collect the appropriate paperwork. The PSA returned and stated that there was no paperwork for this FFP unit and that it did not need to be checked, although the laboratory staff stated they did not speak to the PSA regarding the FFP.
The nurses on the ward took the word of the PSA that they did not need the paper work, and checked the FFP to the patient. The unit was group O, the patient’s blood group was group A, therefore making this an incompatible transfusion. The staff were unaware of this at the time as both medical and nursing staff were under the impression that O was the universal group for FFP as well as red cells. Later the laboratory staff noted the FFP for the patient was still in the fridge and when they checked the register realised the error. They immediately rang the ward; however the product had already been administered. As a result the patient had a mild rise in bilirubin, and his procedure was delayed as a precaution to monitor the patient for further consequences of the transfusion therapy.
Students analyse the clinical incident from the perspective of a new graduate registered nurse or midwife in the first twelve months of practice (see the framework in Chang & Daly, 2016, pp. 278-280). Use the following points to guide your answer:
1. Provide a concise description of the incident (i.e, what happened?)
2. Outline why you chose this incident and how it is relevant to your professional practice
3. Identify the relevant factors in the clinical context that potentially contributed to the incident (i.e., why did it happen…so what?)
4. If you were involved in a similar clinical situation in the future, what alternative actions would you take? (i.e., what would you do differently…now what?)
Support your answers with reference to the relevant clinical and professional standards that apply.
Student directions
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