Perioperative and anesthetic adverse events in Thailand (PAaD Thai) incident reporting study: Transfusion error

Abstract

© JOURNAL OF THE MEDICAL ASSOCIATION OF THAILAND | 2019. Background: The Royal College of Anesthesiologists of Thailand conducted a project named “The Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) study” in 2015. Objective: To determine the incidents, contributing factors, factors minimizing the incident, and suggested corrective strategies for blood transfusion error in “PAAd Thai study”. Materials and Methods: A prospective multicentered observational study was conducted in 22 participating hospitals across Thailand between January and December 2015. A report regarding the incident of perioperative blood transfusion errors was reviewed and discussed to reach a consensus agreement by three anesthesiologists. Descriptive statistics was used for analysis and report. Results: Six incident reports met the criteria. Two patients received wrong A or B pack red cell (PRC), developed serious ABO incompatibility reaction (i.e., gross hematuria), and needed unplanned ICU admission. Another two patients received wrong O PRC but did not experience any reaction. The last two patients received the correct blood groups but with a wrong label in the blood tag and barcode. It was found that most of the incidents occurred during the duty shift of the anesthesia providers. The contributory factors were miscommunication and negligence in the patient identification before the blood transfusion. Conclusion: Failure to follow practice guideline and miscommunication were major contributing factors. Factors minimizing incident were experience, vigilance, adequate equipment, and following the practice guideline. Suggested corrective strategies were clinical practice guideline, improve communication skill, more equipment, and a morbidity mortality conference. Anesthetists’ non-technical skills (ANTS) may also be used to improve patient safety.