Investigation report on blood transfusion incident at Princess Margaret Hospital

Hong Kong (HKSAR) - The following is issued on behalf of the Hospital Authority:

     The spokesperson for Princess Margaret Hospital (PMH) today (June 9) released the findings and recommendations of a root cause analysis investigation on a blood transfusion incident which was announced earlier by the hospital.
     PMH announced a blood transfusion incident on April 6, 2017 and thereafter appointed a panel to investigate the underlying cause of the incident and make recommendations to prevent future reoccurrence. The panel has completed the investigation and the report has been submitted to Hospital Authority Head Office and PMH.
     A 63-year-old male patient who suffered from end-stage renal failure and required peritoneal dialysis was admitted to the medical ward on the morning of April 6, due to peritonitis. As the patient was diagnosed with anaemia, the attending doctor arranged a blood transfusion for him. Blood typing and screening was conducted according to established procedures and the results showed that the blood type of the patient was O positive.
     At around 11.45am on April 6, the blood transfusion procedure was carried out by an Advanced Practice Nurse and a Registered Nurse after verification of the patient's identity.

Two minutes later, the Registered Nurse was alerted by the infusion pump alarm and found that there was around 2 centimetres of air bubbles in the transfusion tubing. She then disconnected the tubing in an attempt to expel the air but was not successful. The blood transfusion procedure was stopped immediately and blood was not infused to the patient. Since the Registered Nurse concerned was engaged in preparing a medication round which would soon begin, she assigned another Registered Nurse to prepare a new set of transfusion tubing to continue with the blood transfusion for the patient.
     After taking over the preparation of the new transfusion tubing, the second Registered Nurse mistakenly connected the new tubing to another 70-year-old male patient staying in the adjacent bed. This patient also suffered from peritonitis but did not require blood transfusion. His blood type was AB positive and the blood transfusion procedure had started. Around five minutes later, the first Registered Nurse discovered the incident and stopped the transfusion immediately.

It was estimated that less than 5 millilitres of blood had been transfused to the patient.
     The doctor in-charge immediately attended to the patient and confirmed that all vital signs were normal. The patient was in a stable condition. PMH explained the incident and extended an apology to the patient's family immediately after the incident happened and announced the incident on the same date. PMH reminded the department concerned to enhance monitoring and remind all the frontline staff to strictly comply with the protocol and guidelines of blood transfusion procedure, including verification of patient's identity. Enhanced mentoring and provision of extra training courses on blood transfusion procedure to frontline nursing staff with less than two years' experience were conducted. Both patients concerned were discharged on April 7 and 8 respectively.
     The investigation panel has interviewed the staff concerned and examined the workflows.

The panel has concluded in their findings that the following three factors are believed to have contributed to the incident:
  1. There was no verification of patient identification before carrying out the blood transfusion
  2. There was inadequate awareness that high risk procedures such as blood administration procedure should be completed by oneself
  3. There was communication breakdown caused by misinterpretation and unclear instructions between the nurses concerned

     The panel has made the following recommendations to the hospital:
  1. Stress the importance of correct patient identification at critical steps during the blood transfusion process (such as sample collection, blood administration and reconnection after interruption during administration)
  2. Perform the assessment upon the transfusion, namely patient identification and procedure verification, on handling reconnection after interruption on blood administration process
  3. Reinforce amongst staff the importance of delivering clear instructions to avoid misinterpretation and encourage staff to speak up and clarify uncertainties
     PMH is highly concerned about the incident and appropriate actions will be considered according to prevailing human resources policy. PMH has been implementing and following up the recommendations to prevent similar incidents from happening again. The investigation findings have been explained to the patients and their families. The hospital extended its sincere apologies to them again. 
     PMH expresses appreciation to the Chairman and members of the investigation panel.

Membership of the panel is as follows:
Dr Clarence Lam, Deputy Chief of Service (Pathology) and Consultant (Haematology), Queen Mary Hospital
Dr Kristine Luk, Hospital Coordinator (Quality and Safety), Princess Margaret Hospital
Ms Eva Ho, Nurse Consultant (Renal Care), Pamela Youde Nethersole Eastern Hospital
Ms Sin Wai-ha, Ward Manager (Obstetrics and Gynaecology), Princess Margaret Hospital
Ms Katherine Pang, Manager (Patient Safety and Risk Management), Quality and Safety Division, Hospital Authority Head Office

Published on: 2017-06-09

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