Abstract

Transfusion medicine is a complex process dependent on a variety of professionals interacting effectively and efficiently across time and distance. To perform safely, professionals depend on their own knowledge and skills, the knowledge and skills of others, and the overall effectiveness of operating systems. Nursing is an essential link in the process. To be effective, nurses need to practice in environments that recognize the importance of reducing error and improving safety through use of nonpunitive system approaches to analyzing near misses and errors. The “off-with-their-heads” approach must be eliminated. To increase efficiency, pathologists and nurses should collaborate on form development, evaluation, and implementation. Documentation regarding transfusions needs to be simplified and coordinated. Knowledgeable staff is an essential element of safe systems. Basic knowledge should never be assumed. Mechanisms to monitor knowledge of key processes along with ongoing feedback and remediation are necessary to maximize performance. Working together, nursing and transfusion specialists will improve transfusion services.

Patient acuity is increasing. Health care systems are becoming more complex. Regulatory agencies are requiring enhanced documentation on an ever-expanding list of data elements. Yet, the resources—both fiscal and human—to meet these needs are diminishing.

Where do these competing realities meet? They meet at the patients' bedside, the emergency department stretcher, or the operating room table. In transfusion medicine, these moments of truth often occur in the hands of a nurse. The last chance for quality control or recovery from previously undetected errors occurs as the nurse prepares to administer the blood product. Therefore, what do nurses need and want to help improve their performance related to transfusion medicine? This article will make recommendations in 3 areas: reducing error and improving safety, documentation, and education.

REDUCING ERROR AND IMPROVING SAFETY

In his 1994 seminal article “Error in Medicine,”1 Lucian Leape brought to the forefront the fact that a substantial number of patients suffer treatment-related injuries and death. As such, during the last several years, there has been increasing recognition of the need to address safety and error reduction issues in health care. For example, the Joint Commission on Accreditation of Healthcare Organizations has emphasized its requirement of root cause analysis for sentinel events and the American Medical Association has created the National Patient Safety Foundation. The intent of these and many other initiatives is to improve health care outcomes by identifying opportunities to improve systems and procedures.

In their article “The Attributes of Medical Event–Reporting Systems,”2 Battles et al describe the design, development, and implementation of a prototype medical event-reporting system for use in transfusion medicine (MERS-TM). The authors recognized that errors in medicine are not unique.3–9 There are important common causal factors that are shared with other industries in which errors can have catastrophic results, industries such as chemical manufacturing, aviation, railroads, and nuclear power. These industries have a history of improving safety by studying near misses as well as actual incidents and errors and improving their systems based on the analysis.

Throughout history, health professions and the health care industry have articulated their commitment to patient safety. Yet, despite this common commitment to safety, there are significant differences between how the health care industry and the chemical, transportation, and nuclear power industries approach the overall issue of safety and error reduction.

One major difference in approach is that the chemical, transportation, and nuclear power industries recognize the importance of near misses. Battles et al define near misses as precursor events or benign errors that cause no harm or lack of an adverse outcome. While thankfully there are few major accidents or sentinel events, there are significantly more near misses. The rationale of reviewing this type of data was presented by Van der Schaaf in his article “Near Miss Reporting as a Safety Tool”10:

Accidents are very rare relative to the number of near accidents and human errors. Fortunate as it may seem, this poses a real problem for complex systems with a high “catastrophe potential” (nuclear power plants, chemical plants, commercial aviation): few accidents means few cases to analyze and hardly any feedback to learn from. This leads to the undesirable situation of ad-hoc corrective measures after each single accident, because the database is far too small to generate statistically sensible preventive measures.

Hence, it is necessary to collect “near miss” data as well as accident data. The much more numerous unsafe situations (both chronic and sudden) and even more abundant human errors not resulting in serious consequences are assumed to have the same root causes as the tiny subset that actually develops into an accident. The same database size may thus be reached much sooner, or a certain observation period may yield a much more reliable insight into the causes of (near) accidents. Also the effects of implemented preventive measures may be monitored and evaluated much sooner and more reliably in this way.

Although anesthesia and pharmacy professionals have undertaken error reduction programs that include near miss reporting, the value of analyzing near misses is only now being recognized by the health care industry as a whole as a critical element in providing a safe patient environment.

In the arena of transfusion medicine, Battles et al applied these concepts in developing MERS-TM. The system, which has 7 major functional components—detection, selection, description, classification, computation, interpretation, and local evaluation—combines existing quality management activities into a near miss incident reporting system. MERS-TM builds on Rasmussen's11 taxonomy for identification of human behaviors and Reason's12 work on human error. Reason believed that human errors are committed when individuals commit either a slip or a mistake. A slip is a skill-based error of either omission (knowing what to do but doing nothing) or commission (doing the wrong thing). A mistake can be either a knowledge-based error (a novel situation is encountered for which there is no standard solution) or a rule-based error (selecting the wrong rule or selecting the right rule but applying it incorrectly).

Another difference in approach to error reduction is that the public and, as a result, the health care industry expects perfection from its practitioners. This leads either to denial that errors are made or takes the “blame'm and train'm” strategy. This is comparable with the chemical, transportation, and nuclear power industries, which tend to use the concept of no-fault reporting. David Blumenthal in his editorial “Making Medical Errors Into Medical Treasures” 13 points out that physicians have “with rare exceptions adopted an ostrich like attitude when dealing with errors. Mistakes have been treated as uncommon and atypical, requiring no remedy beyond the traditional incident reports and morbidity and mortality conferences.” Nursing, on the other hand, frequently takes the opposite position and actively seeks to identify the individual responsible for the error. Once identified, the individual is usually reprimanded and often fired for “unprofessional conduct.”

Smetzer and Cohen in their article “Lessons From the Denver Medication Error/Criminal Negligence Case: Look Beyond Blaming Individuals”14 point out the importance of looking at the impact of systems involved in errors. In this October 1996 case, 3 nurses who were involved in a medication administration error were indicated for criminally negligent homicide. The analysis of the well-publicized case that resulted in the death of a newborn revealed more than 50 latent failures in the system that allowed the error to occur. According to the authors, if even one of these failures had not occurred, the error would not have happened or it would have been detected before harming the newborn. They point out that errors are almost never caused by a single individual or the failure of a single element in a system. Rather, it is the result of numerous latent failures in the system combined with active failures by individuals.

Clearly, few errors are the result of intentional acts. Yet, when health care practitioners make errors, we all too often treat them as “bad people” or now even as criminals. Such actions will do nothing to improve the safety of the system. It will only serve to remove any incentive health care practitioners have to report near misses or actual incidents in an effort to protect their jobs and their licenses.

If transfusion medicine is to be improved, nurses and physicians need to work in an environment that recognizes errors, slips, and mistakes as part of dealing with human beings. An environment that approaches these situations in a proactive, nonpunitive manner will increase the likelihood of creating safe systems and reducing errors in transfusion services.

Institutions need to look closely at their nursing, human resource, and pathology policies and procedures that address errors. Consideration should be given to establishing a nonpunitive system that encourages reporting of both near misses and actual errors. The reporting system should be simple and user-friendly. A format for analysis such as MERS-TM should be implemented. The information derived from the analysis should be shared in a multidisciplinary forum focused on system improvements.

DOCUMENTATION

As regulations increase, the volume of documentation required and the time available to the health care practitioner for documentation decreases, and the need to assure that documentation systems are efficient and effective becomes even more important. Documentation standards in transfusion medicine are often particularly arduous. In most institutions, administering blood products requires documentation on multiple forms. At minimum, this is likely to include a form for ordering the blood product, the blood bag tag, patient intake and output record, transfusion record, and patient care record.

As attempts to improve performance are made, it is reasonable to consider 3 key points. First, wherever possible, simplify. Transfusion forms, policies, and procedures are often crafted with elaborate complexities. Experience demonstrates that a clear, concise approach is infinitely more desirable. Second, avoid duplication. Systems that require duplicate charting are just waiting for repeated audits that demonstrate that the nursing staff is “noncompliant with established standards and procedures.” Therefore, all transfusion-related forms should be reviewed as a package to evaluate for and address duplication. Third, as forms are being developed and/or reviewed, it is critical to do so from a multidisciplinary perspective. Pathology and nursing personnel need to work together from the beginning to ensure that forms address the needs of both parties. Assuming that, of course, nurses will be able to complete the form that was developed by pathologists has led to many unnecessary conflicts between the departments. These conflicts can usually be avoided by recognizing the interdependent nature of the transfusion process and working collaboratively from the beginning to address system issues. The development of computerized patient records will make significant overall improvements in the area of documentation. However, until this desired state becomes a reality, consistent vigilance is necessary to address the need to simplify, avoid duplication, and involve the implementers into the design process.

EDUCATION

Unfortunately, in today's rapidly changing health care environment, the procedures and processes that we consider routine or commonplace often fail to get the attention they deserve. We make assumptions about what physicians and nurses know about transfusions.

We conducted a survey of our physicians and nurses to determine their overall knowledge about blood transfusions (Figures 1 and 2). The physician questionnaire was a 12-question (multiple choice, true/false) survey developed by the Blood Utilization Review Committee. The questions focused on informed consent and transfusion-related risks that the committee felt every physician would know. Participation in the survey was voluntary, and answers to the questions were provided immediately following the completion of the test. A similar test, 14 questions developed by the Nursing Education Department, was administered to nursing staff and focused on basic transfusion techniques and practices. Both groups scored significantly lower (in the 50%–80% range) than anticipated (in the 85%–100% range). Following an educational process, a repeat survey demonstrated significant improvement in all areas. This indicated to us the importance of providing a constant source of information and feedback to all staff involved in transfusion services.

CONCLUSIONS

Transfusion medicine is a complex, multistepped system that depends on a variety of professionals interacting effectively and efficiently with each other across time and distance. To perform safely, each professional depends on not only their own knowledge and skills, but also the knowledge and skills of the team and the overall effectiveness of the operating systems. Beyond that, external agencies have specific requirements for documentation and review.

Nursing is an essential link in the process. To be their most effective, nurses need to practice in an environment that recognizes the importance of reducing error and improving safety through a nonpunitive systems approach to analyzing near misses and errors. The “off-with-their-heads” approach of identifying and punishing nurses who are involved in near misses and errors must be eliminated if transfusion practices are to be improved. Early identification of system problems will be enhanced through a well-established and routine process of collaborative, multidisciplinary reporting and analyzing incidents as they occur. MERS-TM is an example of such a program.

To increase nursing efficiency, documentation of activities regarding transfusion services needs to be simplified and coordinated. Pathology and nursing service personnel need to work collaboratively on form development evaluation and implementation. Duplication between forms needs to be avoided, and nonessential elements removed from preprinted forms.

A knowledgeable staff is an essential element of a safe system. The basic level of knowledge of all practitioners should not be assumed. Mechanisms to monitor knowledge of key processes and procedures should be put in place in all systems. Ongoing feedback and remediation are necessary to maximize performance of all levels of personnel. By working together in a multidisciplinary manner, such as in a Blood Utilization Review Committee, nursing and transfusion medicine specialists will receive and provide the information necessary to continuously improve transfusion medicine.

Figure 1.

Blood transfusion physician survey.

Figure 1.

Blood transfusion physician survey.

Figure 2.

Blood transfusion nursing survey.

Figure 2.

Blood transfusion nursing survey.

References

References
Leape
,
L. L.
Error in medicine.
JAMA.
1994
.
272
:
1851
1857
.
Battles
,
J. B.
,
H. G.
Kaplan
,
T. W.
Van der Schaaf
, and
C. E.
Shea
.
The attributes of medical event–reporting systems: experience with a prototype medical event–reporting system for transfusion medicine.
Arch Pathol Lab Med.
1998
.
122
:
231
238
.
Fischoff
,
B.
,
S.
Lichtenstein
,
P.
Slovic
,
S.
Denby
, and
R.
Kenny
.
Acceptable Risk.
Cambridge, England: Cambridge University Press; 1989
.
Norman
,
D. A.
Categorization of action slips.
Psychol Rev.
1981
.
88
:
1
5
.
Norman
,
D. A.
The Design of Everyday Things.
New York, NY: Doubleday; 1989
.
Reason
,
J.
Human Error.
Cambridge, England: Cambridge University Press; 1990
.
Miller
,
C.
System safety.
In: Wiener EL, ed. Human Factors in Aviation. San Diego, Calif: Academic Press Inc;
.
1988
.
53
80
.
Eyseneck
,
M. W.
Principles of Cognitive Psychology.
Hillsdale, NJ: Lawrence Erlbaum; 1993
.
Rossett
,
A.
Training Needs Assessment.
Englewood Cliffs, NJ: Educational Technology; 1987
.
Van der Schaaf
,
T. W.
,
D. A.
Lucas
, and
A. R.
Hale
.
eds
.
Near Miss Reporting as a Safety Tool.
Oxford, England: Butterworth-Heineman; 1991
.
Rasmussen
,
J.
The definition of human error and a taxonomy for technical system design.
In: Rasmussen J, Duncan K, Leplat J, eds. New Technology and Human Error. London, England: John Wiley & Sons Ltd;
.
1987
.
23
30
.
Reason
,
J.
Generic error-modeling system (GEMS): a cognitive framework for locating common human error forms.
In: Rasmussen J, Duncan K, Leplat J, eds. New Technology and Human Error. London, England: John Wiley & Sons Ltd;
.
1987
.
63
83
.
Blumenthal
,
D.
Making medical errors into “medical treasures.”.
JAMA.
1994
.
272
:
1867
1868
.
Smetzer
,
J. L.
and
M. R.
Cohen
.
Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals.
Hosp Pharm.
1998
.
33
:
640
657
.

Presented at the College of American Pathologists Conference XXXIII, Transfusion Medicine Performance Improvement, which was cosponsored with the American Association of Blood Banks, San Francisco, Calif, August 20–22, 1998.