Blood transfusions are a relatively routine intervention but, globally, the underpinning rationale is significantly different. In high-income countries, 75% of all transfusions administered are to those over 60 years of age for post-surgical treatment and the management of malignancy-related anaemia, as well as sudden trauma. However, in lower income countries, up to 54% of transfusions are for children under the age of 5 years for severe anaemia and in pregnancy-related complications (World Health Organization (WHO), 2021).
Despite the disparity in rationale, issues surrounding safety remain a consistent concern globally, with only 50% of hospitals worldwide having transfusion committees and only 57% having systems for reporting adverse events, prompting the WHO to challenge and promote blood safety for all (WHO, 2021). In addition, the risks relating to transfusions since 2020 appear to have increased and continue to do so, with incidences of error rising in emergency departments within the UK; the Serious Hazards of Transfusion (SHOT) annual report 2020 recorded 2623 errors (Narayan, 2021). This would suggest that learning is minimal and strategies to reduce or eliminate risks are desperately needed.
The National Institute for Health and Care Excellence (NICE) (2015) has produced a guideline on the delivery of blood and blood products transfusion. It included the safety and quality of blood, pre-transfusion compatibility testing, using the appropriate blood component, providing steps to ensure the right patient receives the right blood and monitoring for transfusion reactions. Despite guidance both nationally and locally to ensure patient safety during a blood transfusion, there remains some significant risk, with failure in accurate patient identification being one example (NICE, 2015).
The Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Service Professional Advisory Committee (JPAC) has produced a Transfusion Handbook, now in its fifth edition and currently being updated, setting out the correct procedure for blood and blood product transfusions (JPAC, 2014).
NHS England/NHS Improvement (2021) reported eight incidences of transfusion with ABO-incompatible blood between April 2020 and January 2021. Despite the introduction of measures to improve practice, transfusion errors continue and are largely attributed to human factors (Booth and Allard, 2017). Some 85% of critical incidents in transfusion intervention are due to errors in the process (Bolton-Maggs and Watt, 2020). In the 2020 SHOT report, of the 3214 serious adverse reactions and events related to transfusion reported to SHOT, 2623 were errors (81.6%) that were deemed preventable; only 394 were not considered preventable and 197 were considered possibly preventable (Narayan, 2021:14). Of those errors, 35 resulted in patient deaths and 16 of those were preventable (Narayan, 2021). With 81.6% of errors being preventable, we have a major responsibility in establishing why critical steps in the transfusion process are being missed. Improving the safety of transfusion across healthcare provision is essential and determining causes is the next step in the journey to improvement in patient safety in the transfusion process. Possible reasons for the preventable errors could include lack of knowledge and understanding, cognitive bias, the working environment, frequency of transfusion practice, lack of communication or, in some cases, all of the above.
Narayan (2020) suggested that there is an inherent blame culture in NHS organisations, which leads to a fear of reporting errors, with subsequent under-reporting. Examining errors guides and informs practice, therefore changes in approach are imperative to address patient safety.
Method: data sources and search
A literature search enabled the identification of relevant studies to be included in this review. Computerised databases including CINAHL, Medline and Cochrane were searched, with appropriate key terms used to identify papers that were current (published in the past 10 years) in peer-reviewed publications (see Figure 1). Search terms used were ‘blood transfusion’, ‘knowledge’ AND ‘education’,‘blood transfusion’ AND ‘human error’ and ‘blood transfusion’ AND ‘human factors’. Limiters were then applied, including articles published between 2011 and 2021 to ensure relevance and currency, in addition to considering only those published in English. The search term ‘nurse’ was added to further focus the search. This resulted in 113 papers, which underwent abstract review to ensure relevance to the area of interest. From those identified as relevant, the full research papers were then screened. From this process, six papers were identified as meeting all the inclusion criteria and relevant to the aims of the review (see Table 1).
Table 1. The six studies
| Author, date | Country | Title | Design | Findings |
|---|---|---|---|---|
| Jimenez-Marco et al, 2012 | Spain | A lesson to learn from haemovigilance: the impact of nurses’ transfusion practice on mis-transfusion | Data were collected through anonymous questionnaires. Completed by 614 nurses at 10 hospitals. A multiple regression analysis was used to investigate which mis-transfusion prediction factors were most accurate. The greatest risk in transfusion medicine was human error | Nurses’ education, training, and how often a nurse transfuses are key factors for best transfusion practice. The performance of well-trained nurses who carried out transfusions either daily or weekly and strictly followed the guidelines were associated with a lower mis-transfusion rate |
| Smith et al, 2014 | UK | Does time matter? An investigation of knowledge and attitudes following blood transfusion training | Online survey administered to participants who had completed the Scottish National Blood Transfusion Service Programme. Comparisons made at 6-8 weeks, 12-14 months, and 22-24 months. In-depth interviews conducted with a sub-sample of survey respondents to explore attitudes in more detail | Regular updates are important for those who do not perform transfusions on a regular basis. Education and audit is a key factor in raising awareness of transfusion safety issues |
| Flood and Higbie, 2016 | USA | A comparative assessment of nursing students’ cognitive knowledge of blood transfusion using lecture and simulation | Participants (86) who received a related didactic lecture preceding the simulation were compared with students who did not receive the lecture | The knowledge and skills related to safely administering blood products is universally essential but clinical experiences are limited Human patient simulations allow nurse educators to provide students with safe, standardised learning and hands-on practice including managing rare adverse reactions. Simulation after a related lecture may strengthen cognitive learning, bridging the didactic-clinical gap |
| Kavaklioglu et al, 2017 | Turkey | Determination of health workers’ level of knowledge about blood transfusion. A quantitative study | A survey with 100 healthcare participants | Continuation of in-service training surrounding blood transfusions is recommended to ensure patient safety. Inadequate patient identification, lack of communication and failure to comply with blood transfusion guidelines are contributing factors in mis-transfusion |
| Tan et al, 2017 | Singapore | Designing and evaluating the effectiveness of a serious game for safe administration of blood transfusion: a randomised controlled trial | A clustered randomised controlled trial with 103 second-year student nurses. Randomised into experimental and control groups. Experimental group received a lecture and then undertook a blood transfusion game and completed a questionnaire to evaluate learning experience | Education and training are vital to improve blood transfusion safety and participants who received a lecture and then simulated practice had a better acquisition of knowledge than those who received simulated learning alone. However, for blood transfusion practice this was not sustained over time. Regular reinforcement is recommended to optimise the retention and transfer of learning |
| Sapkota et al, 2018 | Nepal | Blood transfusion practice among healthcare personnel in Nepal: an observational study | A descriptive observational study of bedside blood transfusion procedures in two hospitals, over 10 months | There was a sustained knowledge gap between healthcare personnel regarding clinical transfusion medicine and practice. There were patient complications that could have occurred due to errors in transfusion practice |
Discussion
Within the research papers included in the review, two main themes and several subthemes emerged:
- Human and environmental factors:
- Sampling
- Bedside checks
- Staffing levels
- Teamwork and communications.
- Education.
Human and environmental factors
WHO (2021) stated that patient safety should be managed through a framework of activities such as employing technologies and processes with the aim of reducing avoidable harm. It stated that patient harm is a ‘large growing public health challenge’ (WHO, 2021: 7). There is an urgent need to identify how we can avoid harm and determine the tools and interventions needed to address this challenge.
Human factors were identified as the significant predisposing factors in transfusion errors in one of the six papers included in the review (Flood and Higbie, 2016). According to the Royal College of Nursing (2021), human factors are variables that influence an individual’s performance and may hinder the way people work. These could include a lack of concentration caused by a distraction, such as being interrupted by another staff member, leading to a failure to check patient identification. A human factors approach in health care underpins patient safety (NHS England/NHS Improvement, 2021) and by understanding human limitations the human factors approach offers ways to minimise and mitigate the limitations healthcare personnel may possess. The resultant effect of mitigation would be a reduction in medical errors and associated morbidity and mortality.
Sampling
The collection of pre-transfusion testing samples from a patient is the first step in the chain of events leading up to transfusion error incidents, with a 30% error rate at this stage being identified in the Tan et al (2017) study. These errors could include the incorrect labelling of specimens, resulting in incompatible blood being administered with potentially significant consequences including the risk of mortality (Jimenez-Marco et al, 2012). Policies and protocols in hospital environments dictate process surrounding sampling. For example, samples should be labelled by the collector after collection but not before they have left the patient’s bedside; however, breaches of this protocol are common (Bolton-Maggs and Watt, 2020). Failing to follow procedures and protocols for blood transfusion practice to save time and effort could play a significant part in how and why such errors occur.
Three of the six studies suggested that human error is the dominant cause of adverse events in the blood transfusion process (Jimenez-Marco et al, 2012; Tan et al, 2017; Sapkota et al, 2018). In most instances where the wrong blood components had been transfused, this was attributed to human errors or the contribution of human factors such as organisational and systemic factors. Tan et al (2017) and Jimenez-Marco et al (2012) identified human error as the leading cause of adverse events during a blood transfusion, often resulting in the wrong blood component being transfused. This was deemed the greatest preventable risk in transfusion safety worldwide (Jimenez-Marco et al, 2012). Jimenez-Marco et al (2012) also identified two steps that are crucial in the chain of events leading to transfusion errors: the collection of samples for pre-transfusion testing and checking the patient’s identification at the bedside before the administration of the blood product. Urgent improvement in the accurate identification of blood transfusion recipients, documentation before, during and post-transfusion, and learning from near misses are vital in preventing potential and future errors and maximising patient safety (Pagliaro et al, 2009; NHS England/NHS Improvement, 2019).
Bedside checks
According to Bolton-Maggs and Watt (2020) and Kavaklioglu et al (2017), the failure to properly identify the patient at the bedside when collecting blood samples is a preventable, but recurring, major problem within a clinical setting. It is a requirement that checks are performed at the patient’s bedside (Lister et al, 2021), yet critical steps in the bedside checks are being omitted, incorrectly performed, or not being performed at all (Kavaklioglu et al, 2017; Bolton-Maggs and Watt, 2020). The introduction of barcode bedside checks in all inpatient wards in 2002 in a hospital in Tokyo, Japan (Ohsaka et al, 2008), whereby the transfusion service monitored compliance with 1-hour or 24-hour checks after blood was issued, saw a 97.8% compliance rate. After the initial study period had finished, human error accounted for 811 cases due to failure to complete bedside identification, showing that computer systems do not always prevent human errors (Ohsaka et al, 2008).
Interruptions during the sampling process may contribute to a failure to complete the necessary bedside checks. The risk of adverse events is greater in areas of rapid turnover, including emergency departments, which may be due to interruptions and competing needs within these intensely busy areas (Bolton-Maggs and Watt, 2020). In the 2021 SHOT report, Narayan (2022) reported that there was an increasing trend of errors reported in emergency departments, with the cause being attributed to the difficulties of caring for patients during the COVID-19 pandemic. As we move away from the pandemic, it will be interesting to see whether this trend decreases. To minimise risk, hospitalised patients should wear an ID wristband, in line with national and institutional policies (NHS England/NHS Improvement, 2018), but this is also reliant on checks being conducted.
JPAC has identified that 1 in 13 000 transfusions are administered to the wrong patient, resulting in death in some cases. JPAC recommends key principles should be put into operation when administering blood transfusions, including positive patient identification, good documentation and excellent communication (JPAC, 2020). Adopting these crucial checks could eliminate many of the preventable causes of transfusion errors.
Staffing levels
Carayon and Gurses (2008) identified that there were significant consequences to the heavy workload nurses were experiencing, which was adversely affecting patient safety. They concluded that having insufficient nursing staff correlated with drug administration errors, documentation problems and inadequate patient supervision (Carayon and Gurses, 2008). More recently, distraction, time pressures, workload, competence, noise levels and communication have been cited as factors that continue to contribute to increased risk (Health and Safety Executive (HSE), 2023a). Situation-specific factors such as time constraints, distractions and workloads could lead to staff non-compliance with guidelines, because taking shortcuts could be the only solution to performing the impossible number of tasks required of them (HSE, 2023b).
Blood transfusions, should only take place if there are enough staff to ensure optimal patient supervision (Hurrell, 2014). For example, overnight transfusions should not take place unless clinically indicated because there is an increased risk of errors due to reduced staffing numbers and the challenges associated with observing patients for signs of transfusion reaction in areas where there is reduced lighting, as there would be in a ward area at night. Ensuring the working environment is one within which employees can express their concerns regarding safe staffing levels and be risk averse is crucial when undertaking critical tasks and procedures such as blood transfusions (Leonard et al, 2004).
Teamwork and communication
Flood and Higbie (2016) and Leonard et al (2004) identified that effective communication and teamwork are critical within the blood transfusion process to provide high-quality and safe patient care, especially in such a complex medical procedure as blood transfusion. Excellent teamwork in managing the numerous steps and processes in administering a blood transfusion enables safe practice. A diverse range of practitioners and professional boundaries are involved in the process, so there is potential for error in each step (JPAC, 2014).
According to Turkelson et al (2020) there are a number of challenges in interprofessional collaboration. Workload pressure, tension between teams and poor collaboration may lead to communication failures, resulting in substandard care and potential harm (Blackmore et al, 2018). Effective communication and teamwork not only benefit the patient but also the organisation (Turkelson et al, 2020). Sapkota et al (2018) stated that 77.7% of errors reported to SHOT in 2015 were due to human factors and only 10% of these were not preventable. Improving processes, systems and organisational factors should address the patient morbidity and mortality risks associated with blood transfusion (Stout and Joseph, 2016; Henneman et al, 2017). Bolton-Maggs and Watt (2020) suggested that the use of improved technology such as barcodes, computer-assisted identification systems and the introduction of end-to-end electronic systems may help to reduce errors, but this is not the complete solution.
Education
Educational interventions appeared to have a significant impact on transfusion-related competence (Smith et al, 2014; Flood and Higbie, 2016;Tan et al, 2017; Kavaklioglu et al, 2017).The use of simulated education in pre-registration programmes alongside lectures and seminars appeared to have a positive impact on the competence of nursing students (Flood and Higbie, 2016). This will provide opportunities to practise blood transfusions amid the challenges that happen in real life in a ‘safe’ environment. Simulation also compensates for the fact that exposure to this task in clinical practice may be rare for some students, depending on the disciplines and practice areas to which they are exposed. Although simulation for qualified staff may be adopted, regular training sessions and updates appear to have the greatest impact on competent practice and patient safety (Smith et al, 2010; Yesilbalkan et al, 2019).
There is increasing recognition that we need to expand and build on digital learning provision in order to deliver educational interventions. These should be accessible to all staff and may be the most effective way of delivering the size and scope of education to maximise patient safety and prevent errors linked to the lack of ongoing development (Männistö et al, 2020). For transfusion of blood and blood products, this could be a means of reaching more staff, allowing them to develop innovative thinking, interprofessional working and improve people’s digital literacy (Männistö et al, 2020).
Conclusion and recommendations
Donaldson et al (2021) stated that, despite commitments to enhance patient safety, the level of avoidable harm in health care remains unacceptably high and a different approach is arguably essential. WHO (2019) reported that patient safety is a global concern and that the risk of a patient dying due to a preventable medical accident is 1 in 300. In addition, adverse events attributable to unsafe care is one of the 10 leading causes of death and disability worldwide (WHO, 2019).
An emerging theme was evident within all the studies examined in this review — that there is a substantial knowledge gap and witnessed instances of some suboptimal blood transfusion practice (Sapkota et al, 2018). However, where there was an increase in educational and training interventions, there was a significant impact on nursing competence and evidence-based practice, resulting in increased patient safety. This improvement however, was not sustained, therefore regular updates may be required to maintain competent practice. Investment in staff numbers and education and different approaches in delivering educational interventions need to be considered.
Blood and blood product transfusion intervention has robust clinical guidance in the UK (JPAC, 2014; NICE, 2015). Despite this, preventable errors and lack of adherence to the process continue to feature in incident reports. Further research and training as well as audits on positive patient identification, ABO incompatibility, lack of guideline adherence, organisational and human factors need attention to ensure staff work towards and optimise patient safety.
Human factors play a pivotal role in transfusion errors. Determining the nature of those human factors is essential through enhanced incident reporting, reducing blame culture and harnessing more positive working environments in order to learn and change practice.
Working conditions need to be taken into consideration when conducting further research into blood transfusion errors. Human error is inevitable; however, it is important to ask the question: are the processes robust enough when one acknowledges the changing dynamic of practice and the demanding nature of today’s rapid staff turnover and heavy workload?
SHOT (2020) stressed that it is important for everyone in healthcare to gain knowledge around cognitive bias, and underlined the need for work systems that help recognise and compensate for limitations in cognition, as well as promote conditions that facilitate decision-making. This will ultimately help improve patient safety, which is a fundamental facet of health care. However, to achieve this, it is vital to share knowledge and awareness surrounding potential risks and risk aversion practice with all the professionals involved in patient care, fostering a culture of patient safety (Donaldson et al, 2021).
It is imperative that further research is undertaken examining the working environment to understand and identify behaviours and latent conditions that lead to errors in patient care. Blood transfusion intervention is one area that urgently needs investigation to prevent morbidity and mortality associated with preventable errors. A more standardised approach to global blood transfusion practice may help address the disparity in geographical and environmental areas (Kavaklioglu et al, 2017).
Research cited in this review consisted of either an observational methodology, where the Hawthorne effect (Kumar, 2019) could have had an impact on the results, or questionnaires were sent electronically, which may have resulted in self-selection bias, with only those who felt they could answer the questions on blood transfusion completing the surveys.
Future research is required to further investigate the human factors that are apparent and recognised as predisposing factors in errors. This would allow nurses to understand how errors due to human factors could be addressed and influence practice in this area.
Key points
- Transfusion errors carry morbidity and mortality risks
- Human factors, environmental factors and a lack of education and training all appear to have a negative impact on transfusion safety
- Minimising risk appears to be linked with end-to-end electronic systems
- Education and training would need to be delivered on a regular basis to maintain the impact of learning and improve patient safety
- Enhanced incident reporting will help us understand the factors that contribute to transfusion errors and aid positive changes to practice
CPD reflective questions
- Think about your area and the blood transfusion process: are there potential errors that you can identify?
- How could these be minimised?
- Can you identify potential training activities that would help improve blood transfusion safety in your clinical area?