Never Event Paper II

Submitted By Mcarlile77
Words: 1248
Pages: 5

Blood Incompatibility
Marsha Carlile
Western Governors University
The ground breaking research of Nobel Prize winner Karl Landsteiner paved the way for safer blood transfusions, and his research continues to benefit the 5 million people each year who require transfusions. (“Blood groups, blood”) Adverse reactions to blood incompatibility are rare. Over half of the very small percentages of patients who experience adverse reactions related to blood incompatibility have allergic and febrile reactions. The even smaller percentage of serious adverse reactions is caused by bacterial contamination of the blood product and immune reactions related to the matching of blood type between donor and recipient. (“Blood safety basics,”) Blood incompatibility is considered a sentinel event by The Joint Commission; an event that is unexpected and involves death or serious psychological or physical injury or the risk of such an outcome. Sentinel events are defined by fact that they signal the need for a response and investigation. (“Sentinel event,”) Current research related to the reduction of adverse reactions and blood incompatibility centers around donor hemovigilance, and the scope of adverse reactions due to incompatibility is directly related to the type of blood products that are used in the transfusion.
Event Description
Immune-mediated transfusion reaction is the response of the body’s immune system to incompatible blood. The immune system’s response not only causes the transfusion to be ineffective, but can also result in massive clotting of the blood leading to circulatory collapse, kidney failure, shock and possibly death. The reaction of the immune system depends on the blood product that is transfused. The transfusion of incompatible RBCs results in a hemolytic transfusion reaction, and this type of reaction can be acute or delayed for a period of several days. An acute hemolytic reaction can be life threatening. Often occurring during the transfusion, the patient may experience a feeling of dread, burning at the site of the infusion, fever, and pain in the flanks or back. The clinical outcome of a delayed hemolytic reaction is dependent on the ability of the recipient’s body to produce antibodies and destroy the donor RBCs, and the reaction is much less severe. The most common reaction to transfusion is the febrile non-hemolytic transfusion reaction, which is the result of the transfusion of incompatible WBCs. The body’s reaction to this type of transfusion is typically milder presenting with fever or rigors during transfusion and will resolve without intervention. Incompatible donor platelets cause post-transfusion purpura. In this type of reaction the body produces alloantibodies to the donor platelet’s antigens leading to destruction of the recipients platelets which results in thrombocytopenia, a swift decline in platelet count. This reaction occurs 5-10 days after the transfusion and is named by the purple discoloration of the skin that is a result of bleeding. (Dean, 2005) Finally, Rh factor incompatibility is the result of a woman with Rh-negative blood being exposed to Rh-positive blood cells during the birth of an Rh-positive child resulting in the production of Rh antibodies or during a blood transfusion. This risk increases with each Rh-positive child that is born. The firstborn may have a mild case of anemia and subsequent children will be more seriously affected with severe hemolytic anemia and jaundice and in the most severe cases the child could possibly die in utero. (Salem, 2014). Although severe reactions happen in a small percentage of transfusions, the goal is to improve patient care and to entirely eliminate this sentinel event.

Incidence of the Event
Side effects from any type of blood transfusion are rare. In a National Blood Collection and Utilization Survey conducted in 2011 the rate of adverse reactions in over 14 million WB/RBC transfused units was 0.24% and the rate of severe…