Case Study O6: Transfusion Reaction Coincidental with Failure to Disobey Physician Orders
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- Case Study O6 deals with a transfusion reaction following red cell transfusion that coincidentally involved a nurse following a physician's orders even though they were contraindicated by hospital policies and procedures. The provocative case title is meant to enhance interest.
- This case was based on a study case used to teach nurses at the McGill University Health Centre (MUHC) in Montréal, Québec.
- TraQ has revised the case and added enhancements (discussion sections, self study questions, quiz) and has copyright for this web-based case.
- Case O-6 is the sixth in the "Other cases" series (cases or reports initially developed or published elsewhere). The original case forms the starting point for the TraQ case.
- Like all "Other cases" Case O6 focuses on best practices and standards related to the case, for example:
- Monitoring patients being transfused
- Iinvestigating adverse events
- Importance of critical thinking when confronted by problems
- Responsibilities of health professionals to protect patient safety as related to scope of practice and interaction with other practitioners
- Learning outcomes
- Original report
- Case scenario
- Questions to be considered
- Further Reading
Upon completion of this exercise, participants should be able to do the following:
- Discuss standards and best practices related to monitoring patients before, during, and after transfusion.
- Discuss best practices for investigating a suspected transfusion reaction.
- Explain the responsibilities of health professionals for patient safety as it relates to their scope of practice and other health providers.
- Discuss perceived loss of professional autonomy as an obstacle to collaboration and open questioning within health teams.
- Describe mechanisms that can allow members of different professions to question inappropriate orders and decisions of other health providers in a collaborative environment.
- Discuss education to assure that health providers have the necessary skills to provide expected interdisciplinary checks for patient safety, such as questioning physician orders.
This case derives from an unpublished study case created by Amélie Rivard, Nurse Clinician in charge of Transfusion Safety, McGill University Health Center. Amélie and her colleague Anna Urbanek work as Nurse Clinicians in charge of Transfusion Safety at MUHC. Amélie Rivard retains copyright for the original case.
TraQ has copyright for this web-based case, which has been fictionalized to enhance its educational value. The described events and practices did not happen at MUHC.
Special thanks to the following who kindly provided advice, information, and ideas for the case. [Details correct when case study went online.] The discussion benefits from their valuable input (errors or misstatements are entirely those of the author):
- Gwen Clarke, MD FRCPC (Capital Health, University of Alberta, & Canadian Blood Services, Edmonton, AB)
- Denise Evanovitch, MLT, Dipl. Adult Ed (Technical Specialist, Education and Training, Hamilton Regional Laboratory Medicine Program, Hamilton, ON)
- Kate Gagliardi, BA, ART (Regional Blood Coordinator, Ontario Regional Blood Coordinating Network, Hamilton, ON)
- Ana Lima, RN, HP (ASCP) (Transfusion Safety Nurse, Sunnybrook Health Sciences Centre, Toronto, ON)
- Veronika Pulley, RN (Blood Conservation Program Coordinator [ONTraC], Windsor Regional Hospital, Windsor, ON)
- Amélie Rivard, RN (Transfusion Safety Nurse, McGill University Health Centre, Montreal, PQ)
The essentials of the case: (Hover mouse over words to expand to a definition)
A 26 year old single female living with her parents was admitted for a CSF leak from the nose, fever, lethargy, neck stiffness and pain. She had multiple surgeries in the past and her health status was poorly controlled. She was admitted to the ER on Jan. 9 for brain surgery. A diagnosis of meningitis followed within a few days.
On Jan. 12 a CT scan of the head showed a large amount of intracranial air in the subarachnoid space and ventricular system. There was a moderate hydrocephalus and the size of the ventricular system had progressed. Between the Jan.1213 a drain was inserted via a frontal burr hole, the tip of the drain located in the third ventricule. On the following CT scan the volume of intracranial air had slowly decreased and the size of ventricular system was reduced. The morning of Jan. 19 the physician decided to close the drain and the patient stabilized.
In the afternoon of Jan. 19 patient hemoglobin was dropping quickly and the physician decided to transfuse 2 units of packed red blood cells (PRBC).
Blood Test Results (Reference Range)
Hemoglobin 79 g/L (120-160)
Hematocrit 0.270 L/L (0.370-0.470)
Platelets 503 x 109/L (140-440 x 109/L)
Past Medical History
- Retinoblastoma (bilateral resection and radiotherapy)
- Rhabodomyosarcoma (chemotherapy in 2005)
- Nasal and sinus surgery
- Port-o-cath insertion (Port-o-cath)
Transfusion Service Laboratory
The patient had been tested once before in another hospital as O Rh positive. A type and screen was done, 2 units of packed red blood cells (PRBC) were crossmatched, and one was sent to the patient's ward.
Transfusion - PRBC #1
The first unit was started at 10:55 am. Vital signs were recorded:
- Blood pressure: 130/72
- Oxygen saturation: 96%
- Temperature: 36.9oC
- Pulse: 109/min.
As the nurse was unable to get an infusion rate faster than 1 drop/10sec., she flushed the port-o-cath with 350 U of heparin. The rate did not increase and she replaced the needle with no success. Finding a new IV access was unlikely because patient had poor vein access and would have required a new port-o-cath insertion or a central venous access, not considered possible as the patient was already unstable.
The nurse called the attending physician to explain the situation and charted the conversation as follows:
- Dr. Brown was made aware; he ordered to continue transfusion even if it takes all day
The nurse followed the order and ran the transfusion over a little more than 8 hours. No further vital signs were taken.
Transfusion - PRBC #2
The second unit was started by the same nurse (who was working a 12-hour shift) at 19:15 h. Vital signs were taken with no untoward results. No further vital signs were taken until 20:30 h. when the patient started shaking and stiffness was noted. The transfusion was stopped, the physician was contacted, and the nurse followed standard procedures detailed in the facility's nursing manual.
Vital signs were
- Temperature: 40.9 oC (axillary )
- Pulse: 220/min.
- Blood pressure: 150/99
- Oxygen saturation: 98% on rebreather
The patient presented decerebration but no clonus opisthotonos , no bronchospasm, but loss of consciousness. The patient was given Benadryl IV, bolus 250cc and solumedrol IV push. The patient was then transferred to an intensive care unit.
In the ICU, patient was covered with cooling blanket and received Lopressor x 4 doses, Fentanyl push, Propofol, Dilantin, IVIg boluses, Tylenol. The patient was finally intubated and put into artificial coma. Blood culture was done and blood bag returned to blood bank for investigation.
Upon detecting the suspected transfusion reaction, the transfusion service (TS) was contacted and the TS performed a transfusion reaction investigation according to its policy and procedure manual, eliminating a hemolytic transfusion reaction as the cause.
Because a bacteriogenic reaction was suspected due to fever subsequent to a prolonged transfusion time (8 hrs.+), the hospital microbiology laboratory performed gram stains and cultures of both PRBC contents, as well as recipient blood cultures. All were negative.
Subsequent analysis revealed that the nurse in question required remedial training related to resolving slow running transfusions and critical thinking in general, and also required re-training for how to monitor and document transfusions.
A more systemic problem was identified regarding the responsibilities and related skills of health professionals to provide checks for patient safety as part of the healthcare team. In-service interdisciplinary educational sessions were held to discuss and resolve the issues.
To test your knowledge and as an advance organizer for the discussion section, read and consider these questions:
- What types of transfusion reactions are possible in this scenario of fever following transfusion?
- Can a transfusion be given over more than 4 hours if a physician orders it?
- What can you do if a physician's order contradicts a policy or procedure?
- What could the nurse have done after she saw that the port-o-cath was not running properly?
- What patient consequences could happen if nurses do not properly chart a transfusion and take vital signs for the entire transfusion and a blood component culture is found to be positive?
Proceed to Discussion (includes interactive questions with feedback):
- Part 1: Administering blood products (inc. time limits)
- Part 2: Investigating adverse events (inc. differential diagnosis of transfusion-associated fever)
- Part 3: Scope of practice issues
- Part 4. Education for interdisciplinary healthcare teams
This case study presents a scenario in which a nurse did not follow several key transfusion protocols and procedures, including adhering to the time limit for transfusing blood, monitoring vital signs throughout a transfusion, and questioning orders that contradicted hospital policies and procedures.
Based on laboratory results and a multidisciplinary discussion, staff concluded that a febrile non-hemolytic reaction had likely occurred after the second PRBC and had triggered subsequent events:
- Increased temperature and chills increased intracranial pressure (the drain had been closed the previous day), leading to
- Seizure and convulsions (treated by medication, induced coma, and intubation)
Further analysis resulted in individual re-training and a system-wide education program on responsibilities and skills for providing interdisciplinary checks to ensure patient safety.
Key learning points include:
- Clinical staff who administer transfusions must be trained and assessed in blood administration.
- Monitoring and documenting vital signs must be done for each blood component transfused before, during, and after transfusion according to established policies and procedures.
- Scopes of practice ensure that health professionals have the required education, training, and professional qualifications to perform their duties competently and safely.
- Within their respective scopes of practice, members of the health care team collaborate in providing patient care.
- Perceived loss of autonomy is considered to be a major obstacle to collaboration and open questioning within health teams.
- Nurses and allied health care professionals such as medical laboratory technologists have a duty to question physician orders that are inappropriate or unclear.
Carroll JS, Quijada MA. Redirecting traditional professional values to support safety: changing organisational culture in health care. Qual Saf Health Care 2004 Dec;13 Suppl 2:ii16-21.
Davies C. Getting doctors and nurses to work together BMJ 2000 Apr 15;320:1021-2.
Kleinman S, Chan P, Robillard P. Risks associated with transfusion of cellular blood components in Canada. Transfus Med Rev. 2003 Apr;17(2):120-62.
Mancini ME. Performance improvement in transfusion medicine. What do nurses need and want? Arch Pathol Lab Med 1999;123(6):496-502.
Moore SB, Mary L. Foss ML. Error management: theory and application in transfusion medicine at a tertiary-care institution. Arch Pathol Lab Med 2003;127(11):1517-22.
Salvage J, Smith R. Doctors and nurses: doing it differently. The time is ripe for a major reconstruction. BMJ. 2000 April 15; 320(7241): 1019-20.
Shulman IA, Saxena S, Ramer L. Assessing blood administering practices. Arch Pathol Lab Med 1999;123(7):595-8.
Silva MA, Gregory KR, Carr-Greer MA, Holmberg JA, Kuehnert MJ, Brecher ME; Task Force. Summary of the AABB Interorganizational Task Force on Bacterial Contamination of Platelets: Fall 2004 impact survey.Transfusion. 2006 Apr;46(4):636-41.
Williams PM. Techniques for root cause analysis. Proc (Bayl Univ Med Cent). 2001 April; 14(2): 154-7.
(also see individual discussion sections)
Altogether for Health (editorial, Student BMJ, Jan. 2006)
TraQ's Resource Library (Many resources from many nations)
Case 108 - Transfusion reaction (University of Pittsburgh)
Disruptive Clinician Behavior: A Persistent Threat to Patient Safety (July /August 2006, Patient Safety & Quality Healthcare)