Interviewer for MICU nurse
First Question: Hi, I’m reviewing an event report as part of an apparent cause analysis to present at the ICU M&M conference. We are trying to understand the system errors that led to this patient receiving the wrong blood product. Is there any insight regarding this case that you can provide?
And wait for interviewee to respond
Second Question: Could you tell me more about the blood administration verification pathway?
And wait for interviewee to respond
Third Question: I understand. That seems like a pretty in-depth process to ensure safety during a rapid infusion. Why do you think this verification system failed in this situation?
Interviewer for blood bank manager
First Question: I’m reviewing a case for an apparent cause analysis to present at the ICU M&M conference, I’m helping to investigate a patient who accidentally received a unit of blood that was intended for another patient. Just to be clear, this is not a punitive investigation. Rather, we are trying to understand what system issues contributed to the patient’s care so we can better support patient care in the future. Particularly, we are interested in understanding the process of blood product delivery especially in an emergent or urgent manner.
And wait for interviewee to respond
Second Question: Thank you. You mentioned a MTP was ordered. What happens on your end when an MTP is ordered? Do you usually end up communicating with the unit when an MTP is ordered?
And wait for interviewee to respond
Third Question: That makes sense. Gotcha, you mentioned that for this patient they had 2 units, a blood box and 2 MTPS ordered. Are there usually so many different orders for blood?
Interviewer for MICU fellow
First Question: Thank you for meeting with me to go over this case for our apparent cause analysis investigation. As the MICU fellow for the patient, we were hoping to get your insight into what systems issues allowed this patient to get the wrong blood product.
And wait for interviewee to respond
Second Question: Absolutely, I understand you were not involved in the blood product verification pathway. But to help me fully understand the steps that lead up to blood administration, could you tell me a bit more about the processes of ordering urgent blood for this patient?
And wait for interviewee to respond
Third Question: I see. Do you get any training on running MTPs and the steps involved in leading an emergent transfusion?