Five minutes with . . . Paula Bolton-Maggs

“Earlier this month we published our latest annual report on adverse incidents related to transfusion.1 Our organisation is 20 years old and has had a significant impact on transfusion safety.

“All NHS trusts in the UK now report to our scheme, and we receive 3500 to 4000 reports a year. This year’s report on incidents in 2016 shows that 87% were caused by human errors, quite a few of which highlight mistakes in the nine step, vein to vein transfusion process.

“The fact that a greater proportion of incident reports relate to error is partly because the blood components themselves are much safer, meaning fewer adverse reactions. And the increased number of recorded errors reflects the fact that, in recent years, all trusts and health boards report to us.

“We see certain common themes in the mistakes: one is not identifying the patient correctly; another is taking the blood sample and labelling it away from the patient. People are meant to carry out sampling for blood transfusion as one continuous process, but sometimes the person takes the blood sample, walks to the nursing station, gets interrupted, and labels the sample with the wrong patient details. The margin for error during that time is very wide.

“Transfusion mistakes are very similar to drug mistakes—they’re about miscommunication, failure to prepare or to hand over and document properly, and not following the proper procedures.

“We don’t get involved in investigating individual cases, but I recently wrote to a hospital chief executive where two nurses had been dismissed after a transfusion to the wrong patient. Sacking staff isn’t a solution. People don’t go to work wanting to make mistakes or to cause harm. Dreadful mishaps occasionally happen, and we need to learn from them. If you don’t own up you can’t learn from your mistakes—but fear of dismissal may inhibit reporting.

“And we don’t find out what happens to medical and nursing staff who make mistakes: we call them the second victims, because they’re very upset by what happened.

“In 2016, three ABO incompatible blood transfusions occurred but also 264 near misses, where the mistake was detected before an incompatible transfusion took place. We now recommend that people set up a transfusion using a checklist at the patient’s side to make sure that the right component is being given to the right person and with the right specific requirements. This could save lives.

“There’s no national, standardised way of doing this, but it needs local champions and commitment. The bedside checklist must now be a standard of care. An audit of adherence to a checklist in London found that it was less likely to be used when staff were experienced in transfusion; however, there’s no place for such complacency. Seniority and experience don’t prevent errors resulting from interruption or distraction.

“Our key message is to be safe and to follow all of the checks—just like a pilot.”