Patient safety


47/117 (40.2%) were unnecessarily investigated with repeat compatibility testing and in 29 blood cultures were taken from the patient.


Anti-D Immunoglobulin (Ig) errors In 2022, there were 345 cases related to errors in anti-D Ig management during pregnancy, and the impact of anti-D Ig and routine ante-natal anti-D prophylaxis (RAADP) errors should not be underestimated. l Omission or late administration of anti-D Ig or RAADP accounted for 232/345 (67.2%) cases analysed, of which 51/232 (22.0%) related to patient discharge prior to administration with 26/232 (11.2%) caused by flawed decision- making.


l Administration to a mother carrying a D-negative infant accounted for 34/345 (9.9%) cases, nine due to failure to check cell-free fetal DNA (cffDNA) or cord blood D-types and 11 due to false positive D-types predicted by cffDNA screening.


l Anti-D Ig was administered to mothers with immune anti-D in 22/345 (6.4%) cases, eight resulted from failures to check records.


l D-positive mothers received anti-D Ig inappropriately in 19/345 (5.5%) cases, seven of these were weak D-types, other errors included failure to check results and transcription errors.


l There were 13/345 (3.8%) cases that involved administration of incorrect doses, five of these related to failure to perform Kleihauer testing, cases of under-dosing related to cell salvage and miscalculation of FMH, over-dosing resulting from miscalculation of FMH and challenges around appropriate administration following frequent potentially sensitising events (PSE).


l Anti-D Ig was administered to the wrong woman in 12/345 (3.5%) cases, all resulted from failures in PPID.


lErrors in the handling and storage of anti-D Ig accounted for six cases, two of which were administration of expired products, two


Case study 4


Multiple errors resulted in Wrong Blood in Tube


A nurse asked the phlebotomist to take a group and screen sample from the ‘patient in bed two’. The intended patient had been moved to another bed and no PPID was carried out before or after taking the sample. The phlebotomist then handed the blood sample to the nurse to label. This was done away from the patient’s bedside using the request form.


48 www.clinicalservicesjournal.com I February 2024


Case study 5 Speaking up for safety despite hierarchical barriers


A healthcare assistant (HCA) noticed a registered agency nurse taking two samples for a group and screen at the same time. The HCA challenged the process as this was against the organisation’s policy; however, the nurse stated that they were going to put a different time on one sample. The HCA reiterated safe practice and local policy (that samples must be taken at different times by different people), removed and disposed of the duplicate


storage errors and two administered without prescription.


l Finally, three cases were classified as miscellaneous, and four Right Product Right Patient cases related to errors in labelling of anti-D Ig.


SHOT data continue to demonstrate that errors in anti-D Ig and RAADP management occur in both clinical and laboratory settings. The management of anti-D Ig and RAADP is multifaceted, errors occur at all stages of the process, from the identification of the requirement, ordering, prescription, laboratory issue, storage and administration. The implementation of non-invasive cffDNA screening has undoubtedly improved practice by targeting administration of this blood product to those who need it, both reducing unnecessary exposure to mothers carrying D-negative fetuses and protecting supplies of the product.


Wrong Blood in Tube (WBIT) WBIT samples continue to be a problem with a large increase in reports in 2022 (n=890) compared to 2021 (n=734). Cases from maternity departments make up 40% of the reports. WBIT errors result from two main causes: failure to identify the patient correctly at phlebotomy 353/890 (39.7%) and labelling the blood samples away from the patient 286/890 (32.1%). In 50 reports, the cause of error was not stated. In 159/890 (17.9%) cases where the cause was recorded both errors occurred together. Mistakes can occur at the first contact with the hospital. In five cases, patients were wrongly identified at initial registration. In one case this was associated with the patient being non-English speaking. In another instance a woman was misidentified by clerical staff on admission to the emergency department (ED) because a patient with a similar name was picked from the patient information system. This mistake was detected


sample, and raised a near miss incident on the local reporting system. A repeat sample was taken and sent to the laboratory. The patient in question had no previous blood group on the system. The transfusion practitioner provided positive


feedback to the HCA and escalated the incident to the organisation’s central safety team. They have also incorporated this scenario into mandatory transfusion training.


when the blood group was found to be discrepant with the previous records of the wrong patient. These cases are another reminder that correct patient identification is vital at all times. Overall, 639/890 (71.8%) were attributed to failure to identify the patient at the time of sampling or the sample was not labelled at the bedside. There were seven cases of mix-ups between


maternal and cord blood samples, and two cases where an agency staff nurse (who had not received transfusion training) took samples from multiple patients and labelled them later away from the bedside ‘to save time’. Most errors were detected by laboratory staff, 717/890 (80.6%) during testing or at authorisation of results. In 689 cases blood group data were provided. If these WBIT had not been detected, 320/689 (46.4%) could have received ABOi components with a risk of serious harm or death. NM-WBIT events are caused by the same two errors identified regularly in SHOT reporting for the past 25 years, namely failure to identify the patient correctly at the time of phlebotomy and failure to label the blood samples while next to the patient. Both these errors occurred together in a fifth of all cases. Maternity departments and clinics are high-risk areas. Suboptimal practice is shown to continue, and the systemic reasons behind this should be explored to improve patient safety. Near miss events should be monitored and investigated using human factors principles. In 2012, the British Committee for Standards in Haematology (BCSH, now BSH) guidelines recommended that any patient who has never been transfused should have a second group-check sample taken to reduce the risk of wrong blood transfusions.4 A recent survey of junior doctors and physician


associates in ED demonstrated an alarming rate of non-compliance including 136/209 (65.1%) who reported having taken two group and antibody screen samples together and labelled them at different times.5


Better understanding of the


potential risks introduced and factors contributing to normalised non-compliance is needed.


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