A 68-year-old man with a history of paroxysmal atrial fibrillation, rheumatoid arthritis, and heart failure with reduced ejection fraction is admitted for total hip arthroplasty due to fracture from a mechanical fall. During surgery, the patient develops bleeding, and the surgeon requests packed red blood cells in anticipation of potential transfusion. The blood bank requires a confirmatory patient blood sample for type and cross-matching and sends an empty collection tube prelabeled with patient name and date of birth. The anesthesiologist draws the patient's blood into the tube and returns it to the blood bank, which confirms blood type and releases the blood products. However, the surgical nurse discovers that the name on the blood products belongs to a different patient. Internal investigation of the incident reveals that the collection tube sent by the blood bank was prelabeled with the wrong patient information. Which of the following is most likely to describe an active error in this case?

Question

A 68-year-old man with a history of paroxysmal atrial fibrillation, rheumatoid arthritis, and heart failure with reduced ejection fraction is admitted for total hip arthroplasty due to fracture from a mechanical fall.  During surgery, the patient develops bleeding, and the surgeon requests packed red blood cells in anticipation of potential transfusion.  The blood bank requires a confirmatory patient blood sample for type and cross-matching and sends an empty collection tube prelabeled with patient name and date of birth.  The anesthesiologist draws the patient's blood into the tube and returns it to the blood bank, which confirms blood type and releases the blood products.  However, the surgical nurse discovers that the name on the blood products belongs to a different patient.  Internal investigation of the incident reveals that the collection tube sent by the blood bank was prelabeled with the wrong patient information.  Which of the following is most likely to describe an active error in this case?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1f9_64dc_8f63_d156b557fc9f_MD0005_00 This scenario (based on a real case) involves errors related to mislabeling, a risk factor for potentially catastrophic transfusion errors. In complex systems (eg, operating room, hospital), safety incidents involve both active errors, describing incorrect, proximal actions of front-line personnel (eg, human error); and latent errors, describing system-level, distal failures. As seen in this case, blood transfusion protocols involve multistep safety protocols such as confirmatory type and cross-matching of patient blood prior to release of products. Two active errors allowed incorrectly labeled blood products to reach the operating room: Personnel at the blood bank incorrectly labeled an empty tube and sent it to the anesthesiologist for collection. The anesthesiologist did not double-check the vial before drawing blood into the mislabeled tube and returning it to the blood bank. Safety incidents are rarely isolated results of incorrect individual action; rather, they are enabled by failures in latent, systemic issues or distal causes. Examples of potential latent factors underlying these incidents include: latent factors inadequate staffing of the blood bank, which could have increased workload and fatigue, leading to label confusion (Choice B). organizational policies allowing prelabeling (eg, labeling empty collection tube before drawing blood) rather than bedside labeling (eg, labeling tube after blood is drawn, in the patient's presence). Bedside labeling could have greatly reduced mislabeling risk in this case (Choice C). patient complexity, a distal cause that can increase provider distractibility and pressure (eg, increasing risk of not double-checking) (Choice D). (Choice E) Although inadequate communication by the surgeon is an example of active error, it is less relevant to this case, which involved interactions among the anesthesiologist, patient, and blood bank. Educational objective: Root causes of medical errors include latent errors, describing system-level safety vulnerabilities, and active errors, describing frontline personnel's actions.

A 68-Year-Old Man with a History of Paroxysmal Atrial Fibrillation