Sample Annotated Bibliography Paper on Analysis of a Potentially Sentinel Transfusion Event

Adibi, H., Khalesi N., Ravagh, H., Jafari, M., Reza, A. J. (2012). Root-Cause Analysis of a Potentially Sentinel Transfusion Event: Lessons for Improvement of Patient Safety. Acta Medica Iranica, 50(9): 624-631

Error prevention and patient safety is a key concern to in the blood transfusion ward. The errors can occur at any stage during the transfusion or safety of the patients (Adibi et al., 2012 P. 625). These errors can be a result of mistakes done when identifying the patient, the blood sample and cross-match mistakes, laboratory errors that occur in the collection and labeling of specimens, errors in the selection and labeling of the blood products, or pre-transfusion bedside checks (625).  From the study done by the Harvard medical school practice, about 4% of the hospitalizations had errors that led to either prolonged stay or led to some sort of disabilities (625).  The results also showed that in some incidences especially in the transfusion department, there was a near-miss reporting system whereby the incidence almost happened but was prevented. The root causes of the near-miss were similar to other causes and therefore the corrective action was not to focus on the disciplinary action against the individuals but the corrective actions to address the system vulnerabilities.

The writers of the article did an experiment whereby patients were recorded according to the root cause analysis and framework were taken from the protocol of  NHS and consisted of the identification and the decision to investigate, organize the team involved, gather data from the available delivery problems as well as identifying the contributing factors to the root cause after which they made recommendations and action plans (625). This primary intervention was done using interviews and other root cause analysis techniques. From the observations, it was discovered that within the first few minutes after initiation, blood was being infused into the wrong patient (625-6). This was discovered and the preliminary interventions were started immediately and fortunately, the patient was discharged without any consequence (625).

The service care delivery problem that was discovered according to the authors was attributed to various causes that included the presence of understaffed personnel, incompetent personnel’s in the emergency unit, lack and poor adherence to the established protocols, and the use of relief nurses in the blood transfusion. It was discovered that the problems were caused due to recruitment and employment causal factors (627). At the same time, the experienced nurses were unwilling to be employed in the emergency because of various reasons that included low wages, insufficient benefits, increased responsibility, and job stress. This left the emergency department with incompetent staff who caused various mistakes in the course of their duties. Other problems that attributed to the defects and failures in the transfusion process included poor communication with the patients, lack of motivation, and lack of transfusion skills among others.

To address the situation, the authors indicated that measures were to be drafted that included addressing the provision of an acceptable patient-nurse ratio in the wards. In this, the shift and the emergency supervisor were to be given the authority to recruit nurses from other wards or summon the on-call nurses to compensate for the lack of sufficient staff in the ward.  At the same time, the position of the shift supervisor was to be reestablished (627). The authors indicated that another corrective action that was reached was to reward nurses with bonuses so that they could work in the emergency ward and create a flexible working schedule. In-service training and new employees’ education were emphasized on and practical guidelines were stipulated to be printed so that they could be installed at different wards of the hospital (627). When recruiting, qualified nurses were to be given the first opportunity for relief purposes. It was also indicated that the laboratory and the blood bank were to be revised in terms of the protocol so as to address the confusion at different stages of transfusion.



Adibi, H., Khalesi N., Ravagh, H., Jafari, M., Reza, A. J.(2012). Root-Cause Analysis of a Potentially Sentinel Transfusion Event: Lessons for Improvement of Patient Safety. Acta Medica Iranica, 50(9): 624-631