Patient Safety Event

Published: 2019-12-13 14:30:00
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On a Friday evening, a patient presented in the casualty and emergency care center with a bleeding profuse in the birth canal. This patient had been involved in a local abortion process which failed. Severe bleeding followed the incomplete abortion. By the time the lady was arriving in the casualty and emergency care unit, she had lost much of her blood. After doing some preliminary observation to find out the extent of blood loss, the skin was pale dry lips which indicated dehydration (Johansson, et al., 2012). Following this, the patient was given an infusion of colloids to restore the volume of lost blood and prevent blood vessel constriction and blood clots (Hoffman, 2009). Controlling the source of bleeding was difficult since it was an internal bleeding. Also, restoration of the volume of blood lost was essential to sustain the patient for the next operation. After the trial to restore blood volume with colloids, the next step was to transfuse packed red blood cells since the patient was unstable even after getting infused with 2000ml of crystalloid (Hoffman, 2009). The patient was then transfused with two units of blood that were O rhesus negative as an emergency. The two units were rapidly transfused at the same time. The patient was still unstable since the bleeding was continuous. Following this, another two units were to be transfused plus fresh frozen plasma unit that would provide coagulation factors.

After four units of blood were administered, an FFP unit was transfused also. The FFP (fresh frozen plasma) was to provide coagulation factors which controlled her bleeding (Simon, et al., 2009). The stability did not last for long until when a partner nurse noticed the patient was having chills, itching, and complaining of back pain. The patient presented with dizziness and shortness of breath. These signs and symptoms presented after six hours of medication. Flashing back the medication that had been given to this patient, she had been stable for six hours after transfusion, and now she was getting ready for an operation process for the incomplete abortion. After investigating the possible cause of the symptoms, we found that the patient had received a unit of blood that was B rhesus negative. This medication error happened because the pack was incorrectly labeled and again it was an emergency case.

To detect this, a blood sample from the patient was taken to the lab for investigation of post-transfusion reaction together with a urine sample (Vincent, 2012). According to Dr. Mike, the laboratory scientist, he did a direct Coombs test together with indirect Coombs test to investigate both the in-vitro and in vivo sensitization of the red cells of the patient. Also, blood grouping for the patient was repeated to confirm that the patient was blood group A rhesus positive. From the urine sample, Dr. Mike confirmed that blood was present which indicated hemolysis, and the DAT result was positive. This was an indication that the patient had received one unit which was B rhesus negative. The ABO incompatibility of this medication contributed to the acute post-transfusion reaction (Hillyer, 2009). Dr. Mike also checked the units register from the blood bank together with the cross match test register. Another confirmatory report was done by following the patient's chart and reviewed that she was blood group A rhesus positive. The rest of the blood units were confirmed in the laboratory, and they were found to be strongly blood group O rhesus negative. Nurse Rachel also followed the history chart of the patient and nothing had been documented that could have contributed to the symptoms. The direct Coombs test was again the confirmatory test that the patient was having and acute post-transfusion reaction (Hillyer, 2009). Following the medication error, the following is the chronology of events.

Incident report

Following this incident, the case was reported in the accident and emergency register as a medication error. For communication purpose, the incident was communicated to the concerned parties. The parties involved in the medication included the blood bank staffs, laboratory staffs, and the nurses in charge of the casualty and emergency center. The blood bank staffs were informed of their error in mislabeling the packed blood cells. Although this is an acceptable error, the laboratory staffs were also involved in the medication error since they didn't confirm the blood group of the blood unit. Instead, they followed the blood bank grouping. Their assumption was also answerable in the medication error. From the standard operating procedures, it is mandatory for to confirm a test before reporting. In the incident report, the laboratory staffs were blamed on the error for making an assumption. Regarding the nurse in charge of the casualty and emergency center Ms. Rachel, there was a contribution from this department in the medication error. Within the period the patient arrived in the department for emergency intervention, a blood sample was supposed to be drawn for cross-match. During the colloids infusion period, the laboratory staffs could have done the cross match test and confirm the blood units were compatible for transfusion. Another point in the incident report was that no matter how emergency the case was, to keep the patient stable was essential although extra care was recommendable for the emergency case.


Following the medication error, the disclosure was a bit tricky to counteract legal matters. This issue was solved as an internal problem where countermeasures were taken to compensate for the medication error. According to bioethics, the patient, and the concerned parties have the right to access all information regarding treatment and any recommended therapy. The medication error was also supposed to be disclosed to the concerned parties of the patient. This followed a chain of communication to ensure that the patient safety event was successful. Again, for the success of the safety event, the disclosure by the nurse in charge of the casualty and emergency center informed the concerned parties of the incident. According to tips on case reporting and management skills, this incident was reported as crossmatch incompatibility and not a real human error. Following this, the relatives and friends were informed of the countermeasures to tackle the complication. This disclosure criterion was to avoid legal actions and blame on all concerned medical practitioners. Additionally, the information was disclosed to the patient as a normal encounter and she could recover soon. The reporting criterion ensured that all measures were going to help the patient, confidentiality was observed and all the legal matters were dissolved.

Risk manager investigation

The risk manager used the RCA fishbone tools of investigation to investigate the factors that contributed to the medical error. Using the root-cause analysis tools, the medication error was followed up to the blood bank services. In the investigation, the fishbone tool was used which comprised of four categories. The first RCA tool category was material (Wilson, et al. 2008). Regarding the material category, it had a contribution to the medication error. In this case, the contributing materials were the reagents used to cross-match the blood units. Other materials were investigated, and nothing was found to have contributed to the post-transfusion reaction. The blood lesion was okay. The next category in the fish bone analysis was the environment. Concerning the environment of casualty and emergency center, this area requires rapid and fast intervention to save the patient's live. The environment also exposes the medical practitioners to errors, since fast response is required. Concerning the nature of the casualty and emergency center, the probability of errors is very high as compared to other working areas where the cases are handled slowly. The laboratory staffs also respond to emergency cases rapidly, therefore, neglecting some procedural test. When considering the nature of the environment, it was acceptable for the error to have occurred.

The next category in the fishbone tool of problem analysis was the method (Wilson, et al. 2008). Concerning this category, the method also contributed to the medication error. The method that was used to confirm the compatibility of the blood unit with the receiver's blood was a contributing factor. A shortcut procedure was conducted to confirm ABO compatibility thus contributing to the medication error. In this category, the transfusion criterion was also condemned as a method that contributed to the medication error. During a transfusion process, all details are supposed to be confirmed prior transfusing the blood components.

The last category of RCA tool of analysis was people (Wilson, et al. 2008). The risk manager evaluated everybody who was involved in the medication error. Through the analysis, the risk manager found that everybody had the chance a chance to prevent the medication error from happening. Starting from the blood bank staffs who prepared the blood unit, followed by the laboratory staff who did the crossmatch test to the nurses who transfused the blood unit it was indicative that this personnel had the capacity to prevent the error from happening. Following the first three categories of RCA tool, the risk manager considered the error to be acceptable. The three categories had more weight that contributed to the medication error.


After assessing the root-cause of the medication error by the risk manager, the following remedies were made to ensure such a scenario didn't happen. The first remedy was to make all the staffs aware that any malpractice in the hospital premises will be handled in a legal platform (Hepler & Segal, 2008). The second remedy was illustrating all steps of verification before giving any medication even if it's an emergency case. The steps of verification started with confirmation of biographical data, evaluation of any history of reaction following a particular medication, and lastly confirmation of the viability of the medication being given (Hepler & Segal, 2008). Another remedy was the provision of standard operation procedures to guide every practitioner in case of any confusion. The SOPs were to be used in every procedural medication to ensure that all skills of safety were practiced accordingly. The last remedy following this case was organizing a safety training that was conducted as a continuous medical education (CME). The purpose of CME was to inform other staffs of the probable medication errors and the countermeasures used to handle such cases. The countermeasures included case reporting, results disclosure, and risk assessment.

Resolutions with the patient

Firstly, the patient was informed of the medication error, the probable outcomes following the error and then the interventions steps to treat the outcomes. Following the medication error, the patient was first put under pain relievers. The drug of choice, in this case, was Acetaminophen which reduced the fever and discomfort of the patient. Secondly, another remedy for the patient was being infused with fluids plus other drugs that prevented kidney failure. The prophylactic measures that were used to treat this error included low-dose dopamine and administration of crystalloids solutions that were used for hydration purpose. Another resolution was an administration of osmotic diuresis together with mannitol. Following the above measures, the patient was then assured of her recovery and any other outcomes that may present later which included the post-transfusion reactions that may present after 24 hours. The patient was also informed and convinced about the regulations that were put in place to avoid the medication error. The r...


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