Department of Quality and Patient Safety, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
Section of Medical Safety Management, Tokyo Medical University Hospital, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
J Cardiothorac Surg. 2022 Aug 16;17(1):182. doi: 10.1186/s13019-022-01931-6.
The past half century has seen the near eradication of transfusion-associated hazards. Intraoperative cell salvage while widely used still poses significant risks and hazards due to human error. We report on a case in which blood collected from a patient with lung cancer was mistakenly administered to a patient undergoing cardiac surgery who should have received his own collected blood. The initial investigation found that the cause of the patient harm was violations of procedures by hospital personnel. A detailed investigation revealed that not only violations were the cause, but also that the underlying causes included haphazard organizational policies, poor communication, workload and staffing deficiencies, human factors and cultural challenges.
On August 14, 2019, a 72-year-old male was admitted to our hospital for angina pectoris and multivessel coronary artery disease. Cardiac surgery was performed using an autologous salvage blood collection system, and there were no major problems other than the prolonged operation time. During the night after the surgery, when the patient's blood pressure dropped, a nurse retrieved a blood bag from the ICU refrigerator that had been collected during the surgery and administered it at the physician's direction, but at this time neither the physician nor the nurse performed the required checking procedures. The blood administered was another patient's blood taken from another surgery the day before; an ABO mismatch transfusion occurred and the patient was diagnosed with DIC. The patient was discharged 65 days later after numerous interventions to support the patient. An accident investigation committee was convened to analyze the root causes and develop countermeasures to prevent a recurrence.
This adverse event occurred because the protocol for intraoperative blood salvage management was not clearly defined, and the procedure was different from the standard transfusion practices. We developed a new workflow based on a human factors grounded, systems-wide improvement strategy in which intraoperative blood collection would be administered before the patient leaves the operating room to completely prevent recurrence, instead of simply requiring front-line staff to do a double-check. Implementing strong systems processes can reduce the risk of errors, improve the reliability of the work processes and reduce the likelihood of patient harm occurring in the future.
过去半个世纪，输血相关危害已基本消除。尽管术中回收式自体输血已广泛应用，但由于人为失误，仍存在重大风险和危害。我们报告了一个病例，从一名肺癌患者身上采集的血液被错误地输给了一名接受心脏手术的患者，而该患者本应输入自己采集的血液。初步调查发现，造成患者伤害的原因是医院工作人员违反了程序。一项详细的调查显示，不仅是违规行为导致了这起事件，还有混乱的组织政策、沟通不畅、工作量和人员配置不足、人为因素和文化挑战等潜在原因。
2019 年 8 月 14 日，一名 72 岁男性因心绞痛和多支冠状动脉疾病入院。心脏手术采用自体回收式血液采集系统，除手术时间延长外，无其他重大问题。手术后的晚上，当患者血压下降时，一名护士从 ICU 冰箱中取出一袋手术期间采集的血液，并按照医生的指示进行输注，但此时医生和护士都没有执行必要的检查程序。输注的血液是另一名患者前一天另一台手术采集的血液，发生了 ABO 血型不合输血，患者被诊断为 DIC。经过多次支持治疗，患者在 65 天后出院。成立了一个事故调查委员会来分析根本原因，并制定预防再次发生的对策。
这起不良事件的发生是因为术中血液回收管理的规程不明确，且该程序与标准输血实践不同。我们基于人为因素和系统范围的改进策略，制定了一个新的工作流程，即在患者离开手术室之前就输注术中采集的血液，以完全防止再次发生，而不是简单地要求一线工作人员进行双检查。实施强有力的系统流程可以降低错误风险，提高工作流程的可靠性，并减少未来患者伤害发生的可能性。
