Lessons Learned

Learning from Mass Transfusion Patient Safety Events

Preventing severe morbidity and/or mortality from uncontrolled hemorrhage is a concern for a wide variety of patient populations. Among trauma patients, the American College of Surgeons reports that hemorrhage is the most common cause of death within the first hour of arrival at a trauma center. Among trauma patients, 80 percent of the deaths occurring in the operating room and 50 percent of all deaths occurring in the first day following trauma are related to hemorrhage.

Hemorrhage is also a significant concern among obstetrical patients. According to the Centers for Disease Control and Prevention (CDC), hemorrhage is the fourth leading cause of death for childbearing women with maternal hemorrhage accounting for 11.4 percent of all pregnancy related deaths, just behind infection/sepsis (12.7 percent ).

Developing and implementing mass transfusion protocols can reduce mortality by standardizing the steps for the efficient processing, delivery and administration of large quantities of blood products with little or no warning. Effective mass transfusion protocols should address the triggers for the initiation of mass transfusion, provide guidance for the transfusion process, and outline when mass transfusion efforts should cease.

In an effort to provide a better understanding of the challenges faced by the front line staff involved in the mass transfusion process, we examined the CHPSO database for patient safety reports related to mass transfusion and mass transfusion protocols. An analysis of these reports revealed the following trends and patterns.

Department n Percent
Emergency Department (ED)/ Trauma 47 36.7 percent
Operating Room/ Post-Anesthesia Care Unit (PACU) 31 24.2 percent
Intensive Care Unit (ICU)/ Critical Care Unit (CCU)/ Neonatal Intensive Care Unit (NICU) 20 15.6 percent
Labor and Delivery (L&D) 16 12.5 percent
Not Mentioned 8 6.3 percent
Medical/ Surgical Unit      2    1.6 percent
Radiology/ Imaging                2           1.6 percent
Blood Bank 1 0.8 percent
L&D/ PACU 1 0.8 percent  

The vast majority of reports reviewed were reported from the ED or Trauma Services (36.7 percent, n=47). This was followed by the operating room/ PACU (24.2 percent, n=31), ICU/CCU (15.6 percent, n=20), and L&D (12.5 percent, n=16). The other locations mentioned accounted for 10.9 percent (n = 14) of the total cases.

Issues and factors associated with the reports were categorized based on themes which emerged from the details in the description field. Nearly half of the reports (49.2 percent, n=63) mentioned concerns regarding the appropriateness of the current mass transfusion protocol or deviation from the policy standards. Issues with placing orders were mentioned in 45.3 percent  (n=58) of reports and concerns specifically mentioning Electronic Health Record (EHR) or computer issues were cited in 32.0 percent (n=41) of the occurrences. Documentation issues/deficits (34.4 percent, n=44), communication and/or confusion (24.2 percent, n=31), storage/handling/utilization (34.4 percent, n=44), and concerns regarding delays in the blood products reaching the patient (28.9 percent, n=37) were also common themes noted in the analysis.

Storage, handling and utilization issues were often related to blood products wasted due to not having been stored at the appropriate temperature. Delays, communication, confusion and patient identification were commonly mentioned in cases where there was more than one mass transfusion occurring at the same time or on the same day. One such case involved two siblings, minors, who were involved in a motor vehicle accident. One of the siblings was going to surgery for an exploratory laparotomy due to blunt force trauma to the abdomen and needed the blood products. The other sibling did not require blood products at that time. This resulted in confusion as to which child needed the blood products as there were significant communication and ordering issues during this case.

In another patient identification error related case, a patient suffered a transfusion reaction due to incompatible blood having been given during a mass transfusion. In this case, one of the units placed in the cooler when the mass transfusion protocol was activated was A positive instead of O positive the unit information on the emergency blood release form (O positive) did not match the blood product unit label (A positive).

Issue/Theme n Percent
Policy Concerns 63 49.2 percent
Ordering Issues 58 45.3 percent
Documentation 44 34.4 percent
Storage/Handling/Utilization           44     34.4 percent
EHR/Computer Issues   41     32.0 percent
Delay 37 28.9 percent
Recommend Training or peer Review 33 25.8 percent
Communication or Confusion 31 24.2 percent
Patient ID 12 9.4 percent
Recommend System Changes 6 4.7 percent
Paper Process 5 3.9 percent

If you are a CHPSO member interested in learning more about mass transfusion protocols please join us for the upcoming Safe Table discussion on February 15. While this discussion is intended for a rural hospital audience and will feature cases from rural hospitals, we encourage all members to attend to share concerns, questions, and resources with other member hospitals. Click here for more information. As a reminder, CHPSO Safe Table discussions are confidential and open only to CHPSO members. Click here to see if your hospital is a CHPSO member.

References and Resources:

Acker, SN, Hall, B, Hill, L, Partrick, DA, & Bensard, DD. (2017). Adult-based massive transfusion protocol activation criteria do not work in children. European Journal of Pediatric Surgery, 27(01), 032-035. Available at: https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0036-1587587

American College of Surgeons Committee on Trauma. (2016). ACS TQIP massive transfusion in trauma guidelines. Chicago: American College of Surgeons. Available at: https://www.facs.org/~/media/files/quality%20programs/trauma/tqip/massive%20transfusion%20in%20trauma%20guildelines.ashx

CMQCC OB Hemorrhage Toolkit V 2.0 includes extensive resources from risk assessment to emergency management plans and system level readiness. 

Langston, A, Downing, D, Packard, J, Kopulos, M, Burcie, S, Martin, K, & Lewis, B. (2017). Massive Transfusion Protocol Simulation: An Innovative Approach to Team Training. Critical Care Nursing Clinics, 29(2), 259-269. Available at: http://www.ccnursing.theclinics.com/article/S0899-5885(17)30012-6/fulltext

Tran, MH, Vossoughi, S, Harm, S, Dunbar, N, & Fung, M. (2016). Massive Transfusion Protocol: Communication Ordering Practice Survey (MTP COPS). American journal of clinical pathology, 146(3), 319-323. Available at: http://europepmc.org/abstract/med/27510718

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