New STIR report available

The Serious Transfusion Incident Reporting (STIR) system operates under the Blood Matters program, a joint initiative between the Victorian Department of Health and Lifeblood. STIR provides haemovigilance data and case studies to improve recognition and management of transfusion adverse events and makes recommendations for safer transfusion practice. The latest annual and summary report 2022-23 is now available and can be accessed here.

The report includes 209 validated investigations, 68 procedural events and 141 clinical reactions. Preventable procedural events make up a third of the report. The insights from case studies in the report can help you reflect on your own health services practices. Below is one of the case studies included.

Case study 6: Two-person (double) independent checks not followed correctly

This event was initially reported as procedural – other. However, the patient received a unit of RBC labelled and intended for a different patient. The Expert Group therefore reclassified the event.

A nurse collected RBC from the blood bank for patient X, unit group A RhD neg, as documented on the associated paperwork.

After delivery to the ward, two nurses took the RBC unit to the patient side to perform checks and administer.

The nurses did not perform two-person (double) independent checks. One nurse checked the relevant prescription while the other nurse checked the patient identification band.

One nurse stated they had trouble pronouncing the surname of the patient as per the RBC unit compatibility label. They spelled the surname out several times to the second nurse, who answered ‘yes’, when asked if that was the correct patient.

The first nurse did not look to see that the details were correct.

There were no comments on the checking if the patient details matched the details on the RBC compatibility label. If this check was done, no discrepancy in patient name was noted.

Approximately 100 mL of RBC was transfused prior to staff finding the mismatch in identification between the patient wristband and compatibility label on the unit.

The error was picked up by a third nurse performing checks during rounds.

The transfusion was immediately ceased, and the patient was informed of the error.

During investigation, it was noted that the patient said to the nurses that the blood was not intended for them. Fortunately, the unit was ABO compatible with the patient who received it.

The health service is investigating the use of simulation training to educate staff on the correct 2-person (double) independent checking procedure.

Expert Group determination: IBCT SR3, certainly, ABO compatible

The health service noted that while there was no physical reaction from this event, the patient did suffer some psychological distress.

Learnings: The two-person (double) independent check is still not routinely performed or understood.

Education on the process is important to ensure correct component/product to patient. Simulation training may be a good way to work through the process. It is important to include the patient as part of the checking process (National Standards).

The patient should have been asked to state their name and date of birth, which would have minimised the concern about the pronunciation of the name.

The staff involved did not follow up the reported assertion by the patient that the blood was not for them.

Patients may at times be able to help prevent errors and are certainly an important part of the checking process.

Patient identification checks need to be conducted with the patient, where possible and not to the patient.