Communication as a Source of Transfusion Errors

The 2003 SHOT Report1 reported that almost one-third of cases in which the wrong blood was transfused involved patients who received blood components that did not meet special requirements. Most involved patients at risk of transfusion-associated GVHD for whom there was a failure to provide irradiated components.

This section considers communication policies in general and then discusses specific communication tools for patients receiving fludarabine.

Rationales for Good Communication

Since poor communication is reported as a major contributor to serious transfusion errors, it follows that good communication policies and procedures are essential to safe blood transfusion. This is especially true for patients with special transfusion needs for whom receiving the wrong blood may be fatal, as was the case for the patient presented in Transfusion-associated GVHD after fludarabine therapy in a patient with systemic lupus erythematosus2 (one of the cases that motivated this case study).

This case was the "first report of TA-GVHD after use of a nonmyeloablative agent in an adult patient without hematologic malignancy (other than patients receiving HLA-haplotype homozygous blood components)."As such, the cause was not failure to communicate the special transfusion need of the patient for irradiated blood. The adverse event happened because of not recognizing that the patient was a candidate for irradiated blood products, given that this was first report of TA-GVHD in such a patient.

Fortunately, the patients in the SHOT Report1 who received un-irradiated blood did not suffer GVHD. However, most of these errors were caused by communication failures.

Although no data exist to document how widespread communication failures are, they are probably endemic in large academic medical centers3. The SHOT 2003 Report:1 recommends that:

Mechanisms must be put in place for appropriate and timely communication of information regarding special transfusion requirements

Poor communication is an important cause of adverse events. In the longer term, IT offers robust solutions, but interim arrangements are required and must be locally implemented and audited.

Communication Failures for Patients with Specific Transfusion Needs

The SHOT 2003 Report1 outlines 107 cases in which patients with special needs were transfused with the wrong blood. Of these, 81 involved patients at risk of GVHD for whom there was a failure to provide irradiated components. The following are examples from SHOT 2003 Report (highlighted italics not in original):

Case 10. Lack of awareness of guidelines puts patient at risk.

A 66 year old male patient received fludarabine for chronic lymphatic leukaemia. The ward staff were unaware of the indication for irradiated blood components and so the laboratory was not informed. Over a 5 month period the patient received 13 units of unirradiated red cells.

Case 11. Failure of communication in shared care.

A 14 year old male was admitted for an open lung biopsy following which he bled and required transfusion. He had previously received a stem cell transplant in another hospital in the same Trust, but there was no facility to link the two transfusion laboratory computer systems and the requester was not aware of the previous history. Non-irradiated red cells were given.

Case 12. No notice taken of an informed patient.

An elderly male patient was admitted to hospital A with an ischaemic foot. He informed the ward staff that he required regular transfusion with ?special blood? at hospital B. The ward confirmed with the transfusion laboratory at hospital B that he had an anti-ANWJ but this information was not passed on to the laboratory at hospital A who were undertaking pretransfusion testing. The antibody screen was negative and 3 units of red cells were issued electronically and transfused. The patient had a rise in temperature and a raised bilirubin, and died 8 days later from bronchopneumonia.

General Communication Policies and Tools

Communication errors affect all aspects of patient care, not just transfusion, and are a significant source of hospital errors in Canada.4 Baker et al. note that "the complexity of care in teaching hospitals means that patients may receive care from several different providers, which may increase the risk of AEs [adverse events] related to miscommunication and coordination of care."

A 2004 study in Annals of Family Medicine suggests that most medical errors in family medicine begin with errors in communication.5 Examples of informational miscommunication that led to diagnosis and treatment errors included

  • communication breakdowns among colleagues and with patients (44%)
  • misinformation in the medical record (21%)
  • mishandling of patients' requests and messages (18%)
  • inaccessible medical records (12%)
  • inadequate reminder systems (5%)

Remedies to tackle communication errors that cause medical errors in general include complex, long-term strategies such as:

  • Developing standard operating procedures and tools (forms, letters, patient cards) to facilitate intradepartmental, interdepartmental, and inter-facility communication
  • Implementing methods to train and retrain health professionals to value effective communication and teamwork*
  • Fostering a culture that eliminates communication barriers such as hierarchies within and between professions, and boundaries between departments
  • Developing information management systems, including information technology, to facilitate information transfer

* See, for example, this interdisciplinary course from the University of Alberta: INT D410

More Discussion...


1. Serious Hazards of Transfusion. Annual report 2003.

2. Leitman SF, Tisdale JF, Bolan CD, Popovsky MA, Klippel JH, Balow JE, et al. Transfusion-associated GVHD after fludarabine therapy in a patient with systemic lupus erythematosus. Transfusion 2003 Dec;43(12):1667-71.

3. Chassin MR, Becher, EC. The wrong patient. Ann Intern Med 4 June 2002 Jun2;136(11):826-33.

4. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004 May 25;170(11):1678-86.

5. Woolf SH, Kuzel AJ, Dovey SM, Phillips RL Jr. A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Ann Fam Med 2004 Jul-Aug;2(4):317-26.