Physician error and overtransfusion

Status:

Ready to upload

Record number:

1204

Adverse Occurrence type:

Undue exposure to risk-intervention

MPHO Type:

Red blood cells

Alerting signals, symptoms, evidence of occurrence:

Post transfusion Hb of 16.2 g/dl

Demonstration of imputability or root cause:

An elderly patient had coffee-ground hematemesis and melana. A crossmatch for 4 units of red cells was made. The Hb dropped but was at no time lower than 10.7 g/dL and the patient remained cardiovascularly stable through out. All 4 units were transfused resulting in a post-transfusion Hb of 16.2 g/dL. The junior physician was inexperienced in assessing bleeding patients and worried about blood lost but did not follow National Guidlines for transfusion.

Imputability grade:

3 Definite/Certain/Proven

Groups audience:

Clinical complications

Keywords:

References:

Clinical activities: Medical decision-making, sampling, ordering components, administration and patient monitoring

Suggest new keywords:

hematemesis, melana, crossmatch

Reference attachment:

* SHOT errors, Taylor, 2012.pdf

Suggest references:

Taylor, C. (2012). Clinical activities: Medical decision-making, sampling, ordering components, administration and patient monitoring. In " Hemovigilance: an effective tool for improving transfusion safety", ( R.R.P. DeVries, J-C Faber and P. Robillard, eds). Wiley-Blackwell, Chichester, West Sussex, UK, pp126-143.

Note:

OK ONCE THE CORRECT REFERENCE IS INDEXED (EVI)