MICU nurse
First Response: Thinking back on this case, the whole thing felt very chaotic. We didn’t expect this patient to become unstable as they were floor status just waiting for a bed. When suddenly they were needing stat transfusions, everyone felt a little unprepared. I think this contributed to us transfusing the wrong blood. There were so many people involved in the process including delivering the blood to the room after it arrived due to the sudden and urgent nature that somehow we didn’t realize that the pRBC meant for another patient on the unit was accidentally transfused for this patient amidst all the chaos.
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Second Response: Normally, the verification process for blood administration involves two nurses verifying the correct product for the correct patient before every transfusion. This should occur during routine processes and emergent rapid infusions. In a rapid infusion process, however, some other things are different from the routine. To expedite blood getting into the patient a manual review station is set up to verify the blood directly outside the room. A sticker with the patient identification is placed on a paper rapid infusion record. The blood product units are checked in and verification is completed with two individuals using the sticker on the form to verify the pts name and MRN against that on the unit of blood product. You also have to verify the product type and unit number, donor ABO and Rh type matches information on blood tag label. The tag attached to the unit should not be removed from the blood product until after the blood is transfused.
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Third Response: One of the issues is during an emergent situation, multiple people can be involved in the handling of the blood products including checking the blood, verifying, grabbing it from the tube station, hooking it up to the Belmont and the patient. This can contribute to confusion during the verification process. Also, the people checking the blood during an emergent process like an MTP may not know the patient receiving the blood, this increases the risk of the name not being correctly verified. Finally, they bled so rapidly and needed so much blood, I think everyone on the unit just assumed any blood that came up would be for him. Maybe that is how it could have happened.
Blood bank manager
First Response: Hmmm…I wasn’t involved into this case but in reviewing it looks like the team placed many separate orders for emergent blood in the system including 2 units of emergency packed RBCs, a massive transfusion protocol twice and a balanced box of blood. We completed the order for the two units of pRBC in ~ 15 minutes which is how it usually takes and sent it through the tubing system and then worked on completing the box of blood and MTP order. I’m not sure why there were several sequential orders for blood ordered but we completed what we saw coming in through epic.
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Second Response: Every time an MTP or a balanced box of blood is ordered in the EMR, we start thawing out the blood to prepare for delivery. A runner should be assigned by the clinical unit to come get the blood (both for the MTP and the box of blood) and we continue preparing units until the team cancels the MTP order. This requires both cancelling the MTP order in epic and a verbal communication to us that the order was cancelled. We don’t regularly initiate communication with the team until something requires clarification.
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Third Response: Hmmmm….looks like first it was 2 units of stat blood ordered, then before those even reached the floor a MTP was ordered then cancelled almost immediately and a balanced box of blood was ordered and then another MTP order was placed 20 minutes later. The order of escalation for blood products usually is stat blood products, then balanced blood box, then MTP depending on how many products the team thinks they’ll need. Unfortunately, a myriad of ordering and cancelling different blood (units, boxes, MTP) is not uncommon. Epic doesn’t recognize units of blood, blood boxes, and MTP all as a continuum of the same thing, blood. Instead, they are totally separate orders. So you can order all of them at the same time and the blood bank ends up with all these competing orders. The problem is that this can lead to wasted blood and a lot of confusion for us as to what the team actually wants us to do. Plus like I said before, a MTP needs to be cancelled both verbally and in the EMR. So between overlapping orders for blood (units, box, MTP) and people forgetting to cancel the MTP it’s pretty easy to end up wasting blood.
MICU fellow
First Response: I didn’t realize that we transfused the wrong product until I came in for my shift the next day and one of the nurses told me about the error. I guess it was discovered later when a nurse for another patient couldn’t find a unit of blood that had been ordered and sent up for their patient. Apparently this unit arrived during the same time span in which the patient needing the MTP was decompensating. After some investigating, they found the other patient’s unit of blood hanging in the MTP patients room empty. I honestly don’t know what happened to allow that to occur as I was not involved in any of the blood verification steps.
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Second response: Sure, I initially asked for 2 units of pRBCs stat when they called me in that the patient was hypotensive and unstable as my suspicion for bleeding was high. Unfortunately, he was becoming unstable extremely quickly and was vomiting blood. I asked for an MTP since they were clearly hemorrhaging, but I’d never ordered a MTP before and the charge said we would need to assign a runner to the blood bank to consistently get bring the blood up. I realized I didn’t really understand the process for the MTP so decided to just order a blood box instead since I knew that worked just like a stat unit of blood and I knew we would need multiple blood products. Unfortunately, the blood box was taking too long so I ended up ultimately asking for an MTP again. I didn’t realize until later that the balanced box also needs someone from the unit to go get it. I wasn’t actually doing the ordering as I was in the room running things. The resident was placing the orders. But I didn’t give them much direction unfortunately. I learned later we were supposed to also cancel the MTP after we were done which I don’t think we ever did.
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Third Response: No, not really. It is just like institutional knowledge and learning on the job but I heard they are interested in changing that. I learned later that MTP’s are really protocolized. The team lead is supposed to assign roles for running the Belmont, blood verification and running to the blood bank to acquire the blood. Since I didn’t know, I really didn’t effectively assign roles or check on the status of blood coming up from the blood bank or ensure that the double verification process was happening. I think I could have been a more effective leader with more training.