In the News...  

Royal Devon and Exeter Hospital Investigates Errors of Wrong Blood Type on Transfusion
7/8/2013
Two so-called "never events" occurred in a Devon hospital last month, it has emerged.

In one of the events, at the Royal Devon and Exeter Hospital, a patient received a transfusion of the wrong blood type, sources confirmed.

The other involved a tube being fed into a patient's heart unnecessarily. 
Hospital managers confirmed they were investigating how the two incidents happened and said providing safe care was their "top priority".

The incidents are categorized by the Department of Health as “never events” because they are so serious they should never happen.

Using the wrong blood type in a transfusion can harm or even kill a patient.

Possible reactions include an acute hemolytic transfusion reaction (AHTR), when the immune system reacts to the donated blood and begins attacking the blood cells.

The second error was giving a patient an unnecessary angiogram. Angiograms are an invasive test where dye is injected directly into the heart's arteries.

It is important that there is an investigation and any lessons are learned so there is not a recurrence”

Chief nurse Em Wilkinson-Brice said: "Providing safe care is our top priority. We are currently investigating two incidents and are in touch with both families."

A spokesman said: "Never events are by definition always a matter of concern and it is important that there is an investigation and any lessons are learned so there is not a recurrence."


To view the origional article, CLICK HERE


Pedagogy believes the critical component to patient safety is EDUCATION! Transfusion Therapy in the Adult Patient is a 4 hour continuing education course designed for nurses caring for the adult patient receiving transfusion therapy. There are various blood components infused for very specific purposes, and each component requires knowledge related to that specific product. Blood product transfusions require advanced nursing knowledge beyond that required for the provision of general infusion therapy. Therefore, education related specifically to the administration of blood products is crucial to the safe and effective use of these components. To view all details, course description, accreditations and to purchase and begin education, CLICK HERE
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