Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).
BACKGROUND
One of the most frequent causes of transfusion-associated morbidity or mortality is the transfusion of the wrong blood to the wrong patient. This problem persists in spite of the incorporation of numerous procedures into the pretransfusion checking process in an effort to improve patient safety. A qualitative study was undertaken to understand this process from the perspective of those who administer blood products and to identify concerns and suggestions to improve safety.


METHODS
Twelve focus group discussions and seven individual interviews were conducted at six hospitals in five countries (n = 72 individuals). Health care professionals from a variety of clinical areas participated. Data analysis identified common themes using the constant comparison method.


RESULTS
Five major themes emerged from the analysis: the pretransfusion checking process, training, policy, error, and monitoring. Findings include the following: staff were aware and appreciative of the seriousness of errors and were receptive to continuous monitoring, the focus was on checking the bag label with the paperwork rather than the bag label with the patient at the bedside, training methods varied with most perceived to have minimal effectiveness, and access to policies was challenging and keeping up to date was difficult. Other factors that could contribute to errors included high volume of workload distractions and interruptions and familiarity or lack of familiarity with patients.


CONCLUSIONS
Multiple factors can contribute to errors during the pretransfusion checking limiting the effectiveness of any individual intervention designed to improve safety. Areas of further research to improve safety of blood administration were identified.
Department of Medicine and McMaster Transfusion Research Program, McMaster University, and Canadian Blood Services, Hamilton, Ontario, Canada. heddlen@mcmaster.ca
Nancy M
NM
Heddle
Mark
M
Fung
Tor
T
Hervig
Zbigniew M
ZM
Szczepiorkowski
Lorella
L
Torretta
Emmie
E
Arnold
Shannon
S
Lane
Michael F
MF
Murphy
D001787:Blood Group Incompatibility / Q000401:mortality / Q000451:nursing / Q000517:prevention & control*; D001803:Blood Transfusion / Q000379:methods / Q000451:nursing* / Q000592:standards*; D057189:Checklist / Q000379:methods / Q000592:standards; D017144:Focus Groups; D006801:Humans; D007297:Inpatients; D038622:Internationality; D019300:Medical Errors / Q000517:prevention & control*; D009740:Nursing Staff / Q000592:standards*; D010045:Outpatients; D010355:Patient Identification Systems / Q000379:methods / Q000592:standards; D017751:Safety Management / Q000379:methods*; D013192:Staff Development / Q000379:methods