In this case study, the shipping containers had been validated to maintain a temperature of 1-10o C (34-50o F) for 24 hours for an ambient temperature of 15 o-30 o C (59-86o F). What errors or poor practices, if any, related specifically to transporting blood, were made by staff at the:

  1. Blood supplier

    Errors or poor practices (none)

    Blood supplier staff did not include a temperature monitor with the shipment. Their  SOP specified that one was required for ambient temperatures >20o C (68o F). When the blood was initially shipped at 11 pm Friday, the temperature was 15o C (54o F).

    Staff though that the blood would reach Hospital A by early morning when the temperatures would not have exceeded 20o C (68o F).

    Under these circumstances, not including a temperature monitor seems reasonable. Supplier staff could not be expected to anticipate and plan for a long delay involving transportation to a second facility (Hospital B).

  2. Hospital A

    Errors or poor practices (italicized below)

    When the RBCs arrived at Hospital A at 7 pm on Saturday, it was still 28o C (82o F) after a high of 35o C (95o F). Staff believed that the blood would reach Hospital B within the maximum 24 hour shipping time. However, in the rush to ship the blood with the patient, staff did not:

    • notice the absence of the blood monitor

    • recall that the shipping box was validated for a maximum of o C (86o F). 

  3. Hospital B

    • did not notice the absence of a blood monitor and was unaware that one was needed for temperatures > 20o C (68o F)
    • was unaware that the temperature that day was outside the container's validated temperature range
    • did not consult anyone before deciding to enter potentially unsafe blood into inventory (even though unsure of what to do)

    Errors or poor practices (italicized below)

    When the RBCs finally arrived at Hospital B at midnight, the technologist noticed the 25-hour shipping time, but:

    Mitigating factors were that the technologist had not been trained in inter-hospital transport procedures and had not undergone competency assessment in more than 2 years.