Who should be responsible for ensuring that there is a written order for transfusion before blood is issued and infused?

A colleague from Oregon reports an adverse event that went something like this: A type and crossmatch was ordered. The medical ward was informed that the crossmatch was completed and that "the blood is ready". An RN responded "Send the unit over", and the unit was dispensed and infused. The doctor who ordered the type and crossmatch testing asked, "Why was my patient transfused, I never ordered anything but a type and cross?" The Oregonian's hospital policies require that the transfusionist confirm that there is a written order and a consent for transfusion in the chart before starting the infusion. Unfortunately, this policy is not always followed reliably. The inquiring colleague believes that this adverse event has an element of training deficiency, but he is not sure if there isn't a system issue underlying the problem. One of their corrective actions is to add a line on their transfusion tag which requires the transfusionists to document that consent was obtained and that a written order for transfusion was confirmed. However, the Oregonian is concerned this won't fix the problem. His questions are as follows:

• Has anyone else faced this problem and how did they solve it?
• He is considering requiring that the transfusion service have the 'give order' in hand before they issue product. This approach might work, but the technologists object to being the hospital's 'policemen', and feel this won't be logistically practical.

The following responses have been received.

ADDENDA April 11, 2003

1. A colleague reports that at her facility they had a similar transfusion incident, and that the nursing department tried to pass the blame to the transfusion service. She adds that part of the patient medical record is computerized (but the technologists do not have access to those records), part of the medical record is paper, and there are numerous instances where verbal orders are honored without much documentation (in either the electronic of paper record). She is of the opinion that it is logistically impossible for a technologist in the laboratory to know what is going on at a nursing station on a medical or surgical floor. She is determined that their policy will remain that the patient identification is presented for blood to be dispensed, and that having an additional line of text on a transfusion slip (as suggested by the inquiring colleague) will probably not work, because it is ultimately a training issue. She concludes with the opinion that when contract and travelling nurses are required to perform functions they have not been trained for, these incidents will continue.

ADDENDA April 14, 2003

2. Another colleague reports that they, too had a similar problem, especially with orders concerning platelet transfusions. Now they require the nursing service personnel to bring a copy of the blood product transfusion order to the transfusion service each time a unit is being picked up; they do not use a tube system to transport blood products. Also, they have a rubber stamp that the laboratorian applies near the written order which has blank spaces for the person issuing to fill in the time/time/and their initials. This ensures that the laboratorian really did check the order. The responding colleague summarized their experience by saying that at first this seemed like a great burden for the transfusion service to assume, but in reality it only takes a bit of effort considering the added safety benefits.

ADDENDA April 28, 2003

3. A transfusion medicine colleague in Northern California reports that their institution uses an "Issue Form" which must show patient's name, BB wristband number and written order for transfusion for them to issue blood to hospital transporter. This "Issue Form" was their response to an inspection deficiency many years ago. Although this "Issue Form" may be considered just another piece of paper, according to the responding colleague there have been several instances in the past where this system has prevented the issue of blood to the wrong patient or the wrong product type to the patient. Their Medical Director and Laboratory policy reflect a strong belief that transfusion is one area that cannot be compartmentalized into a nursing function or a laboratory function. They don't consider themselves "policemen", but that all departments must work together to have a system of checks that ensures the patient gets the proper blood product and the best care they can provide. Working with the nursing department to create these systems has been beneficial. Together the Transfusion and Nursing Dept. have developed a one page outline for blood administration that they issue with the blood product. The responding colleague adds that the transfusion service has received numerous favorable comments about this outline from the nurses, especially from the registry and floating RN staff.

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