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Question 1: Mistake-proofing is commonly used in transfusion services. 

1. List 5 examples that have been standard best practice for years.
2. Which of these are designed to prevent communication errors?

Question 2: Mistake-proofing technological devices are increasingly used by transfusion services.

1. Briefly describe 3 of the newer mistake-proofing devices.
2. Which types of errors are most of these designed to prevent?

a. Newer mistake-proofing tools include:

• Barcodes on patient wrist bands, blood specimens, crossmatch request forms, and donor bag compatibility tags
• Radio frequency identification (RFID) (e.g., in patient wristbands)
• Barrier systems (e.g., blood bag secured with a combination lock)

b. The newer mistake-proofing devices are designed to prevent identification errors.

Question 3: What are some of the limitations of technological mistake-proofing devices?

Limitations of the newer technological devices include:

• Expensive to implement
• Technical limitations (new devices always improve over time)
• Require many users to identify all of the problems
• Lots of practice is needed for staff to maintain proficiency and confidence 
• Scanning bar coded wristbands may fail (food stains, crinkles, etc.)
• Technology cannot totally replace effective interaction between healthcare workers

Question 4: Transfusion errors have many causes, including misidentification, training deficiencies, work overload, faulty communication, and more. 

1. Does faulty communication play a major or minor role in causing serious transfusion errors?
2. Which types of patients are especially at risk from communication errors?

a. Faulty communication plays a major role in serious transfusion errors.

b. Patients especially at risk from communication errors include those with special transfusion, for example: 

• patients requiring irradiated blood components
• patients requiring CMV-negative blood components
• patients with clinically significant antibodies

Long-term strategies used to prevent communication errors include:

• Developing SOPs and tools such as forms, letters, and patient cards to facilitate communication between departments and facilities
• Training staff to value effective communication and teamwork
• Eliminating communication barriers such as hierarchies within and between professions, and boundaries between departments
• Developing information management systems to facilitate information transfer

Concrete examples of how patients on fludarabine therapy may received incorrect (un-irradiated) blood include:

• Ordering physician does not recognize that patient needs irradiated blood 
• Need for irradiated blood does not follow the patient from facility to facility
• Need for irradiated blood is not  flagged in the laboratory information system (LIS)
• TS laboratory fails to retrieve patient history 
• LIS fails to identify patient as needing irradiated blood 

Examples of communication mechanisms that can be used to increase transfusion safety for patients with special needs include:

• Transplant program sending a letter to the TS, advising the TS of the patient's identity, date of transplant, and transfusion requirements 
• Pharmacy department, clinicians, and nurses notifying the TS whenever a patient is started on therapy with purine analogues such as fludarabine 
• Using forms such as a "Request for Special Blood Products" that clinical staff complete and send to the TS
• TS adding markers and comments in LIS patient history to indicate type of blood product required, transplant date, drug history, etc.
• Using an LIS that can block issuing anything but products that meet a patient's special needs
• Sending a letter to the patient's physician and the patient explaining the need for special products and asking patients to show a wallet card that accompanies the letter
• Using medic alert bracelets to document special transfusion needs
• Conducting in-services about the importance of special transfusion needs and ways to provide safe blood

1. How can patients help increase their own transfusion safety?
2. Provide example of how healthcare workers can facilitate this.

a. Patients can increase their own transfusion safety by taking an active role, for example, they should:

• Communicate special transfusion needs to healthcare staff 
• When available, show evidence of these needs (e.g., letters and wallet cards)
• Question staff immediately prior to transfusion to ensure that special requirements have been met

b. Healthcare workers can facilitate an active patient role by:

• Fostering a climate in which patients are encouraged to communicate with healthcare providers, and question them
• Providing information (letters, wallet cards, pamphlets) to patients that documents their need for special products
• Asking patients to show the letter and wallet card to health providers

Question 9: Heathcare is increasingly interdisciplinary. Which health professions are involved in the transfusion needs of patients taking purine analogues such as fludarabine?

Health professions involved in transfusion of patients taking purine analogues include: 

• physicians
• nurses
• medical laboratory technologists/scientists
• pharmacists

Question 10: How do regulatory standards address the need for effective communication mechanisms for patients with special transfusion needs such as irradiated blood?

In general, regulatory standards require that there be an established 

• policy defining when irradiated cellular blood products are required to prevent transfusion-associated graft-versus-host disease 

• process to ensure that recipients of irradiated products continue to receive them as long as clinically indicated

Such policies and processes are required for all special transfusion needs, not just irradiated blood. They also require effective communication between everyone involved in blood  transfusion.

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