Sunday, September 07, 2014

Stand by me (Musings on effects of errors on transfusion professionals)

Updated: 9 Sept. 2014
Recently, I browsed the Speaker abstracts and Poster abstracts for the BBTS annual conference to be held 24-26 Sept. in Harrogate, UK. The abstracts were published online 26 August 2014 as free full text. At the same time, I happened to be reading the UK's 2013 SHOT Report published in July. One abstract and a section of the 2013 SHOT coalesced to form the idea for this blog.

September's theme relates to all transfusion professionals, whether lab technologist/scientist, nurse, or physician. The blog’s title derives from a 1961 song by Ben E. King, covered more than 400 times and featured in a 1986 movie of the same name.

Of all the fascinating BBTS abstracts, the one chosen to build a blog around is under 'Clinical Audit/Service Improvement Short Paper Orals':
  • SI27. An exploratory research study into the effects of staff feelings and perceptions following a transfusion incident investigation. Transfus Med 2014;24 (Suppl. 2):19. 
    • By D. Creighton (SNBTS Edinburgh) and M. Wright (Glasgow Caledonian University, Glasgow)
The reason this abstract resonates is that in a long career as a lab technologist, supervisor, and educator I've been involved with and privy to many serious transfusion errors and their effects on the professionals involved.

What follows are my musings on the BBTS abstract and related personal memories, as well as what the 2013 SHOT Report says about causes of human error. The focus is on the effects that errors have on those who make them, realizing that it is patients who suffer irrevocable, sometimes fatal, consequences.

As an aside, with a background as a medical laboratory technologist (biomedical scientist) and transfusion science educator, what I like about the 2014 BBTS meeting is how many talks and posters directly relate to transfusion professionals who work in the laboratory.

As noted, the abstract that stimulated the blog is by D. Creighton and M. Wright of the SNBTS Edinburgh, and Glasgow Caledonian University, Glasgow, respectively. Please read the complete abstract (Further Reading). My précis of it is as follows:
  • Most research on transfusion errors focusses on procedural errors, not human factors or staff emotions. This research examined the emotional impact of errors and contributing factors.
  • Researchers recruited and interviewed staff involved in a transfusion error and analysed results.
  • Of 12 staff, five agreed. The main human factors acknowledged by four participants were distraction and a busy work environment when the error occurred. 
  • All five expressed disbelief they had been involved.
  • Four were affected emotionally, experiencing insomnia and decreased confidence. 
  • Most worried about confidentiality and other staff knowing they’d made an error. 
  • Support was mainly positive but two participants experienced negative reactions from colleagues. 
  • All learned lessons which they would carry forward and share with colleagues. 
  • Participants’ reactions directly correlated to error severity and potential patient outcome.
The authors conclude that human factors need to be included in training packages. Reactions and feelings of staff involved in errors can be overwhelming and support is crucial.

With the advent of quality systems and hemovigilance, transfusion medicine has long had a no-blame culture (at least in theory), as have health care systems in general. For example,
A no-blame culture is critical for patient safety. Health professionals must feel comfortable with reporting errors, including their own, so that hemovigilance and quality improvement programs can detect, analyse, and help prevent them in future. In an effort to encourage error reporting, we use blame-free terms such as events, incidents, and occurrences. Despite the talk, 'walking the talk' of no-blame attached to individuals who make errors is a tough slog.

Below are two memories of transfusion-related errors I was involved in with serious consequences.

Memory #1 
Years ago when working in a combined centralized transfusion service/blood centre, one weekend when on shift by myself, I crossmatched a group AB patient for several RBC. The following Monday I was also working when the call for more blood came through. We had to order a new specimen as there was no more patient serum. (Yes, in olden days we routinely used clotted blood samples for pretransfusion tests and even patients without clinically significant antibodies were crossmatched by indirect antiglobulin test and more.)

Much to my horror the patient now typed as group O. I’m sure my entire insides shook as a colleague redid the patient’s ABO on the earlier sample. Absolute personal relief when it typed as group AB.

The transfusion service did the usual follow-ups. Called to stop any transfusions, asked how many RBC had been transfused and if patient was experiencing any signs and symptoms of a hemolytic transfusion reaction, requested new blood specimens, etc.

The patient experienced a severe hemolytic transfusion reaction but survived.  It’s amazing how resilient the human body is, even for those ill enough to be transfused:
We later learned that a hospital nurse had drawn the blood specimen from the wrong patient. Both the group AB and O samples came from patients in the same hospital room. And the RN in question was the highly respected liaison we dealt with at that hospital, the one who drew many of the blood samples and maintained the onsite ‘blood bank’ (refrigerator and associated request forms and records).

The effect on the implicated RN is unknown. Was the patient's family told what had happened? I doubt it. The effect on me - I’ll never forget it. 

If I had mistyped the first specimen, would I have been fired, even though it was the first ‘critical incident’ (or any error) I’d been involved in? Perhaps. That was a long time ago, pre-quality systems, when the concept of ‘system error’ was unheard of in health care. We were not unionized and worked long (indeed outrageous) hours without time off.

But before being fired, I suspect that I’d have resigned from the guilt and shame of having made the biggest error a lab technologist can make, mistyping a patient’s ABO group and putting a patient's life at risk. Because ABO errors can cause death, they require 100% accuracy, no room for error. Could counselling have helped? Maybe. Even more important would be the support, understanding, and ongoing respect of colleagues.

Of interest, the 2013 Annual SHOT Report reports 9 ABO incompatible red cell transfusions in 2013 and one patient death with the incompatible transfusion as a contributory factor.

Memory #2 
Much later, while employed as a university professor and clinical instructor for the transfusion service at a tertiary care hospital, one of my students made an error that caused a patient’s premature death. The error per se did not cause death but hastened it.

What was the error? Something so simple. Something that can happen if concentration wanders, or strategies are not in place to prevent them, or practitioners don’t follow procedures.

While performing antibody screens, the student mis-pipetted one patient’s serum into another patient’s tests. As a result the patient was transfused with incompatible red cells and subsequently died. I documented the error as a TraQ case study for the BC Provincial Blood Coordinating Office.

Although not directly involved with the error (the student was supervised by an experienced, exemplary technologist), I observed the aftermath first hand. The main effect was that the experienced, supervising technologist, one of the best, with great potential, soon left the lab for a career outside health care. Could this have been prevented? With proper support, I believe so.
  • TraQ's Case A8: Severe Hemolytic Transfusion Reaction Involving a Student (see Further Reading)
When we make mistakes, our first reaction is to deny them. For example, as an instructor I noticed that students who made pipetting and other mistakes would invariably claim something like, “I KNOW I added the right things’, where ‘things’ could be patient serum, reagent red cells, etc. My response was always,
  • ‘Of course, you thought you were adding the right things to the tests. If you knew you were adding the wrong things, you’d stop and would not add them.’ 
Fortunately, because such errors are often easy to demonstrate, students could accept their errors, learn from them, and move on.

Sometimes, especially as students, we progress to blaming circumstances for our errors. And sometimes circumstances do play a role as when staff are overworked, morale is poor, and training and competency assessment are inadequate. These are the so-called system errors where the system is faulty and affects all involved.

A fascinating feature in the 2013 Report is the inclusion of the MHRA hemovigilance team's analysis of serious adverse events (SAEs) reported to Serious Adverse Blood Reactions & Events (SABRE).
  • Medicines and Healthcare products Regulatory Agency (MHRA) Report on Blood Safety and Quality Regulation in 2013 (See pp. 27-41)
In 2013, 2.9 million blood components were issued in the UK with only 705 SAE reports submitted. Human error accounted for 689 (97.8%) of the SAEs, where an SAEs is defined as
‘Any untoward occurrence associated with the collection, testing, processing, storage and distribution, of blood or blood components that might lead to death or life-threatening, disabling or incapacitating conditions for patients or which results in, or prolongs, hospitalisation or morbidity.’
In brief, reports to SABRE showed that those making errors were aware of their local SOPs, which were complete and current. Individuals were either busy with urgent work when the error occurred (especially during out of hours shifts), or were otherwise distracted. In either case the result was an error due to a lapse in concentration.

Of all reported human errors, a lapse in concentration was the largest single cause, accounting for 35.6% (245/689) of errors. The next largest category related to omitting procedural steps or not following the correct procedure. About two thirds of all SAEs could have been prevented had correct procedures been followed.

The advice that especially caught my attention in the MHRA report:
  • Formal re-training is often proposed as a corrective measure but is usually only appropriate if the individual did not understand their initial training. If a trained, competent member of staff makes an error, the root cause will seldom, if ever, be addressed by re-training. 
  • Look for other reasons for the error, e.g., for an error due to loss of concentration when rushing, investigate why the staff member was rushing. Possible causes include a busy workload due to an emergency, poor planning, staff shortages due to lack of resources, or poor staff management
Being rushed is a reality for health professionals, now more so than ever. A major complicating factor has long been staff shortages and under-staffing caused by repeated health care restructuring, ongoing cutbacks to postsecondary education and health care, and more.

When errors happen, we in the TM community espouse a ‘no blame culture’. Sometimes it’s real, sometimes it’s pretence, in that, despite the nice words, staff are blamed and stigmatized.

But as the BBTS meeting abstract shows, we typically don’t consider the emotional effects of making errors on those involved. It’s all cool root cause analysis, perhaps targeting ‘system error’ as the culprit, but more often resulting in ‘training issue’ as the catchall for whatever goes wrong.

How the staff involved feel is seldom considered and, besides re-training, their emotional well being is largely ignored. At most a caring colleague might ask, 'Are you okay?' with the individual involved seldom replying honestly.

No-blame culture aside, making errors devastates health professionals and undermines confidence.  In some ways, that’s preferable to brushing off errors with, ‘Oh well, sh*t happens’. But without support, a serious error can have long-lasting negative effects on individuals and co-workers alike. Even well meaning colleagues may be critical, never overtly express it to those involved, thinking it could never happen to them, or secretly thinking, ‘Thank gawd that wasn't me!’

A critical issue is that we acknowledged making errors as human. If we haven’t made one yet in the lab or on the wards, we likely haven’t worked long enough. Or is it that we are perfect? Hmmm…. Tempted to say, ‘Let he who is without sin [error], cast the first stone.'

In that vein, I love this BMJ piece:
As an instructor I tried to model these words to show students it’s okay not to know. Who can know everything with today’s rate of knowledge turnover and technological advances? Don't know? Let’s find out.

Maybe we should add, ‘I made a mistake’ as three words we acknowledge but don’t let define or destroy us.

We’re all in this world together and must support each other, especially when the going gets tough. As health professionals, any one of us is capable of making a devastating error. Support and compassion are not only kind but validate our humanity.

Think of this song the next time a colleague screws up. Could be you, yes it could.
I'll end by asking you to find 19 minutes to watch Dr. Brian Goldman's TED talk on physician error. That may seem a lot of time in our busy lives but think of all the time we waste on the Internet and television each day. You won't be disappointed with Goldman's talk. His message applies to all of us. Perhaps you can listen to it on your next walk or jog or over lunch?
As always the views are mine alone and comments are most welcome.
Meeting abstracts and resources like SHOT reports and TraQ's case studies are free continuing education and a great way to keep abreast of new developments and what’s trending. They make great bathroom (toilet/loo) reading to while the time away so that life’s baser functions serve a higher purpose.

Why not skim them online and then print content of most interest for later reading? Or print for discussing at staff meeting or journal clubs. Do journal clubs even exist any  more?