Q1. Prevention of Errors and Patient Management
Blood products are considered medications and thus should require the same level of precautionary measures as when a nurse administers a drug to a patient. Errors in blood product administration can be prevented by learning and adhering to applicable guidelines. According to the Australian and New Zealand Society of Blood Transfusion (ANZSBT, 2011), a checking procedure should be undertaken for blood products prior to transfusion. The nurse must check that the blood group as indicated on the product is compatible with the patient’s blood group as indicated on the laboratory compatibility label (ANZSBT, 2011).
In case there are different blood groups on the product and compatibility label, there must be a note from the transfusion service provider that these are compatible (Australian Red Cross, 2012). Without this note, the inconsistency will need to be resolved first with the transfusion service provider prior to administration (Australian Red Cross, 2012). Compliance with this step in the checking procedure would have led to the nurses discovering that the compatibility label read O negative but that the product stated O positive. Without a note indicating compatibility despite this discrepancy, the nurses should have decided not to transfuse the blood product.
In addition, the guidelines also recommend reconciling the blood product, including special requirements if any, written on the prescription to that in the compatibility label and product (ANZSBT, 2011). The donation or batch number written on the product and the compatibility label must also be the same (Australian Red Cross, 2012). Furthermore, ensuring the correct product also includes checking that the expiry date and time have not elapsed (Australian Red Cross, 2012). Besides adherence to the checking procedure, having a qualified colleague validate the compatibility of the product and identity of the patient at bedside is also one strategy to guarantee the transfusion of the correct product (Australian Red Cross, 2012).
The venous access device, blood administration set, procedures for priming, connecting or flushing the line, filter (if necessary), infusion device, concurrent medications and fluids, and the blood warmer device uses, as well as the timing and location of transfusion must all adhere to guidelines (ANZSBT, 2011). Appropriate caution must be taken to prevent medications from being co-administered with the blood and for the blood warmer temperature not to exceed the limit. In addition, the speed of transfusion must be within the recommended range to prevent circulatory overload if too fast or risking RBC damage and bacterial contamination if administered for over 4 hours (Brunskill et al., 2012).
Close monitoring is a key component of the nursing management of an individual receiving a blood transfusion. Protocols state that serial measurements of the temperature, pulse, blood pressure, and respiratory rate should be made at least before a pack is transfused, 15 minutes following the start of transfusion, hourly afterwards, and after the entire pack is administered (ANZSBT, 2011). Comparisons with the baseline should be made to ascertain changes that may indicate adverse, potentially fatal reactions. Visual observations of the patient must also be carried out to detect signs of circulatory overload, anaphylaxis, and other adverse reactions. Transfusion should be stopped immediately but with the normal saline line open if a serious reaction is suspected. The patient should be assessed and appropriate management undertaken.
Q2. Competency Standards
Competency standards pertain to the minimum required knowledge, skills, and attitudes that a registered nurse must possess to competently and safely practice nursing (ANMAC, 2012). Standard 1 on critical thinking and analysis was breached (NMBA, 2016). Whereas there are national guidelines on blood product administration, the nurses failed to strictly comply with it when they made the decision to transfuse the incompatible product. It is possible that they only considered the blood type but not the Rh factor when they performed the checking procedure. However, knowledge of blood transfusion principles would dictate that an Rh negative patient cannot receive Rh positive blood. In addition, informed decision-making also makes use of a variety of evidence such as current and relevant knowledge, guidelines, legislation, and experience which is also consistent with the code of professional conduct for nurses (NMBA, 2013).
Similarly, there was a breach of Standard 6 pertaining to the provision of safe, responsive, appropriate, and quality nursing practice (NMBA, 2016). This is because the nurses failed to practise according to the guideline relevant to the task. It is possible that they were not aware that blood group checking not only involves the blood type but also the Rh factor and this may relate to the lack of education, training, and experience. Still, Standard 3 on maintaining the capability for practice would still have been breached (NMBA, 2016). If nurses think they lack the knowledge, skills, and experienced required for safe blood product administration, it is their accountability and responsibility to seek related learning opportunities and guidance to ensure they are capable in this task. This is consistent with the provisions of the code of professional conduct for nurses (NMBA, 2013).
A root-cause analysis (RCA) is a framework used to analyse how and why an adverse event occurred and what needs to be improved to prevent similar incidences in the future (Mahlon et al., 2012). To arrive at a good understanding of the event, one must use objective data to trace the steps that led to it and compare these to what should have been done as dictated by guidelines, laws or policies (Mahlon et al., 2012). Such data includes information from the patient’s chart and incidence reports. Subsequently, errors can be identified and the underlying reasons rooted out. As such, the RCA team will need facts about the event.
The report should thus contain the name of the person making the report, what the incident is, and the time and place of its occurrence. An explanation of what happened in its proper sequence must be given. This includes what was done to retrieve the blood product, prepare for transfusion, perform checks on the patient’s identify and patient-product compatibility, administer the product, and monitor for adverse reactions. The outcome must also be described in terms of assessment data such as the patient’s vital signs and observations. Finally, the corrective actions taken when the adverse reaction was discovered must be narrated. Care must be taken not to include subjective information such as thoughts, feelings or opinions in the report.
References
Australian and New Zealand Society of Blood Transfusion (2011). Guidelines for the administration of blood products. Retrieved from https://www.anzsbt.org.au/data/documents/guidlines/ANZSBT_Guidelines_Administr ation_Blood_Products_2ndEd_Dec_2011_Plain_Tables.pdf
Australian Nursing and Midwifery Accreditation Council (ANMC) (2012). Registered nurse accreditation standards. Retrieved from http://www.anmac.org.au/sites/default/files/documents/ANMAC_RN_Accreditation_ Standards_2012.pdf
Australian Red Cross Blood Service (2012). Flippin’ blood: A bloodsafe flip chart to help make transfusion straightforward. Retrieved from http://resources.transfusion.com.au/cdm/ref/collection/p16691coll1/id/20
Brunskill, S., Thomas, S., Whitmore, E., McDonald, C.P., Doree, C., Hopewell, S., Murphy, M.F. (2012). What is the maximum time that a unit of red blood cells can be safely left out of controlled temperature storage. Transfusion Medicine Reviews, 26(3), 209-223. doi: 10.1016/j.tmrv.2011.09.005.
Mahlon, C., Sanchez, N., Gondek, S., McAuliffe, J., Kent, T.S., Christein, J.D., & Callery, M.P. (2012). A root-cause analysis of mortality following major pancreatectomy. Journal of Gastrointestinal Surgery, 16, 89-103. doi: 10.1007/s11605-011-1753-x
Nursing and Midwifery Board of Australia (NMBA) (2013). Code of professional conduct for nurses. Retrieved from http://www.nursingmidwiferyboard.gov.au/Codes- Guidelines-Statements/Professional-standards.aspx
Nursing and Midwifery Board of Australia (NMBA) (2016). National competency standards for the registered nurse. Retrieved from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines- Statements/Professional-standards.aspx
