MEDICAL NEGLIGENCE PATIENT SAFETY 1.7A
BLOOD TRANSFUSION MISTAKE
John Whelan with Specialist expertise in Medical Negligence and Patient Safety gives an example of a case which falls outside of the definition of a Notifiable Incident as envisaged by item 1.7 of the Patient Safety Act 2023. This example involves similar mistakes to that envisaged by item 1.7 of the Act but yet since it doesn’t lead to the death of the Patient it is not a Notifiable Incident as defined by Item 1.7. This example is one of many cases which should fall within the ambit of the Patient Safety Act and can be introduced by a Ministerial regulation under Section 8.
Item 1.7A
A Notifiable Medical Incident involving Blood Transfusion Mistake
A notifiable medical incident involving a blood transfusion mistake, such as administering the wrong blood type, can be life threatening and is classified as a "never event" in healthcare. These mistakes are preventable with proper verification and safety protocols, but when they occur, they can lead to serious complications for the Patient.
Example: Wrong Blood Type Transfusion
A male Patient with severe anaemia due to gastrointestinal bleeding is admitted to the hospital. He requires an urgent blood transfusion to stabilise his condition. The blood bank prepares and sends a unit of blood, but due to a mix up in the blood typing process, a unit of type B blood is mistakenly sent instead of the required type O negative blood, which the Patient needs.
The nurse administering the blood transfusion is not vigilant during the identification process and proceeds to infuse the wrong blood type. About 10 minutes into the transfusion, the Patient begins to show signs of an acute haemolytic transfusion reaction (HTR), including fever, chills, back pain, and a sense of impending doom. Blood tests confirm that the Patient has received the wrong blood type.
The blood type verification process between the blood bank and the nursing staff was not performed correctly.
The patient’s identification and the blood product were not double checked before administration.
The nurse failed to confirm the Patient’s details and blood type against the blood product tag before initiating the transfusion.
The Patient experiences a severe haemolytic reaction, where the immune system attacks the transfused red blood cells, leading to the release of harmful substances that cause widespread damage.
The Patient requires emergency treatment, including fluid resuscitation, diuretics, and renal dialysis to address potential kidney failure caused by the transfusion reaction.
The Patient’s recovery is significantly delayed, and additional therapies are required to stabilise his condition.
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