Preventing Fatal Blood Transfusions: Why Frequent Patient Monitoring Saves Lives

By Genevieve Valek


Many people choose the hospital they go to for care according to the hospital’s reputation. A patient in need of aggressive chemotherapy, for example, might base the decision according to the reputation of a hospital’s oncology division, or as part of a thought process that reasons, “If this hospital is known for its outstanding oncology program, I am safer and more likely to recover while in their care.” Unfortunately, this is not always the case.


No one should die from a blood transfusion. It is a simple and extremely common procedure for patients needing intensive care or undergoing surgery. However, at the MD Anderson Cancer Center in Houston, a 23-year old leukemia patient died as a result of a blood transfusion that had become contaminated with bacteria, according to an NBC News report.

How could something so easily prevented become lethal? There is no evidence that anyone at the nation’s top-ranked cancer hospital according to U.S. News and World Report was actively monitoring the woman’s vital signs in the moments after the transfusion, the NBC News report said. A scouring investigation conducted by the Centers for Medicare and Medicaid Services (CMS) uncovered systemic safety lapses at the hospital. Nurses were not properly monitoring patients’ vital signs while conducting blood transfusions. This occurred not only in the case of the patient who died, but during 18 out of 33 other cases examined.



Many hospitals don’t have the technology to track frequency or quality of patient monitoring


How does this happen? Some may blame it on a system error; others may say a lack of strong protocol enforcement. Many hospitals don’t have the tracking technology to hold nursing staff accountable for how many times they check on a patient in a day, unfortunately. Fatal blood transfusions are so rare and preventable that they are considered by experts at the Agency for Healthcare Research and Quality (2019) as something that should never happen. Other things on this “never event” list include leaving medical equipment inside a patient after surgery, or giving patients contaminated drugs.


Such errors are shocking to the public and cause distrust in the hospital system between patients and caregivers. Fatal blood transfusions happen enough, unfortunately, to be considered a prime example for why hospitals must become better at preventing never events. Of 17 million blood transfusions in 2017, 37 patients died as a direct result, according to the Food and Drug Administration.


As a result of the fatal error and subsequent investigation, MD Anderson submitted a plan of correction to CMS, including making immediate changes to nurse training and requiring hourly checks on patients during transfusions, the NBC report said. In addition, the hospital announced the launch of a command center to continuously track the vital signs of every patient receiving a transfusion at the hospital. These are changes every other hospital should adopt.



Vitalacy has developed workflow monitoring and purposeful rounding technology


In an effort to help hospitals reduce harmful errors by overcoming patient safety challenges, Vitalacy has developed automated location-based technology that monitors nurse workflow and rounding (Nour-Omid, 2019).


Using blue tooth sensors and smart devices, this workflow monitoring and purposeful rounding solution tracks nurse-patient interactions to help hospitals learn if safety procedures and policies are being followed. By helping to ensure adequate frequency and duration of patient room visits, this approach improves the quality of room visits and helps prevent adverse events and healthcare-acquired conditions such as fall injuries, pressure ulcers and deep vein thrombosis while resulting in improved Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores.

This workflow monitoring and purposeful rounding solution features customized “heat map” reporting by room and by caregiver. Using these features, unit managers can identify gaps in rounding by keeping track of hourly visits, verifying which staff visited which patients, and reviewing visit durations to see if staff rounds meet all hospital requirements.


It is a hospital’s responsibility and duty to the patient to learn from mistakes, and sometimes mistakes must happen to spur positive change. Let’s hope that one day, the accidents on the list of “never events” can be prevented from ever happening again.


Genevieve Valek is a multimedia journalist and public health advocate.


References


Agency for Healthcare Research and Quality. Patient Safety Network. Never Events, Jan. 2019.


Centers for Medicare and Medicaid Services. Conditions of Participation (CoP). Provider Plan of Correction. The University of Texas MD Anderson Cancer Center.


Food and Drug Administration. Fatalities Reported to FDA Following Blood Collection and Transfusion. Annual Summary for Fiscal Year 2017


Hixenbaugh, M. No one should die from a blood transfusion. So why did it happen at MD Anderson, the nation's top cancer hospital? NBC News, June 26, 2019.


Nour-Omid, J: Introducing Vitalacy’s latest product updates: workflow monitoring & purposeful rounding. Vitalacy Blog, Feb. 20, 2019.

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