SNPG927 - Promoting Clinical Excellence: Transfusion Reaction Report

This report examines transfusion reactions as critical patient safety indicators, focusing on clinical excellence and healthcare quality. It explores the causes and consequences of transfusion reactions, including hemolytic reactions and the importance of accurate blood transfusions. The report emphasizes the role of nurses in preventing errors and improving patient outcomes, discussing the application of the PDSA quality cycle to address clinical reasoning errors. It highlights the significance of provider-level indicators, the need for continuous improvement in healthcare practices, and the importance of patient satisfaction and safe patient practices. The report also provides insights into the impact of clinical errors, poor diagnosis, and the need for improved quality of care within the hospital setting.

Running head; transfusion reaction 1
Transfusion Reaction
Student’s name
Institutional affiliation

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Patient quality indicators or patient safety indicators can be defined as mechanisms that
are undertaken to evaluate adverse situations that take place due to previous exposure to
treatment. The patient quality indicators are those conditions that can be controlled or improved
by adopting high quality treatment, by either improving care skills or the model of care. There
are several patient quality indicators that vary depending on the type of care that a hospital or a
health organization largely offers. According to Rizk, Sawhney, Cohen, Pike, Adler, Dominitz,
& Wani, (2015) such indicators include Laceration, obstetric trauma, failure to rescue, post-
operative wood dehiscence and transfusion reaction among others. This paper examines
transfusion reaction as an example of patient safety indicator.
Transfusion reaction or hemolytic reaction refers to a serious complication that occurs
after blood transfusion. The reaction is triggered by difference in the rhesus factor of the donor’s
and the recipient’s blood argues (Beck, Young, Erickson, & Prats, 2017). Transfusion reaction is
known to cause a condition known as agglutination. Transfusion reaction involves the clamping
together and destruction of red blood cells that a person receives during blood transfusion by the
individual’s immune system. This happens as an allergic reaction. Destruction of the red blood
cells makes it hard for the body to perform important functions that are performed by the red
blood cells such as packaging and transportation of oxygen and other substances throughout the
body.
Transfusion reaction happens due to the fact that the body has the capability to detect
foreign substances (Berwick, 2016). That notwithstanding, the body produces antibodies that
fight and destroy the blood cells that have been detected and identified as foreign to the body.
This is often caused by lack of compatibility of the blood that is donated with that of the
recipient. The recipient’s blood reacts against the transfused blood and hence destroys the red

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blood cells by causing them to clamp together. Transfusion reaction is a safety and quality
indicator as it results from failure of the nurses to fully examine blood before performing a
transfusion. It is therefore required of nurses to carefully examine blood in order to ensure that
the blood that is being transfused is compatible with that of the recipient to avoid such a reaction.
Klein, & Anstee, (2014) argues that It is possible to identify a transfusion reaction within
the first two days of a blood transfusion. This is because it can be observed through some of the
most observable signs of a transfusion reaction. These signs and symptom include mild fever,
urticarial and shivering however, these are only minor symptoms that do not persist for a long
period of time. The most serious symptoms include a characteristic loss of breath due to
destruction of the red blood cells. The loss of breath is often observable as the patient gasps for
breath occasioned with unconsciousness and fever. Another major symptom is red urine from the
patient. At this point, the reaction is considered fatal and requires serious interventions.
Transfusion reaction can be measured by administering rapid tests. The main aim of the
tests is to be able to distinguish hematuria from hemoglobin in urine. Hemoglobin presence in
urine (hemoglobinuria) indicates a transfusion reaction (Skeith, Valent, Marshall, Pereira, &
Caughey, 2018). Hematuria on the other hand refers to the presence of blood in urine due to
bleeding in the urinary tract. The difference between hematuria and hemoglobinuria is that the
former may show red blood cells settling at the bottom of the tube when a centrifugation is
conducted while the latter remains red in color even after centrifugation. This simple test
together with the signs and symptoms discussed earlier are the established ways in which a
transfusion reaction can be identified and quantified.
Transfusion reaction once identified requires immediate and serious attention as it is
likely to lead to death explains Heidenreich, P. A. (2018). Once a transfusion reaction has

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occurred, a nurse is supposed to stop the transfusion and administer normal saline (0.9% sodium
chloride) through the line. It is then important to conduct a clerical check to identify what
triggered the transfusion reaction. Possible causes of transfusion reaction are, wrong labelling of
the blood or the patient, wrong identification of blood from the blood bank or the patient’s blood.
Conducting the clerical check is also important distinguishing whether the condition is a
transfusion reaction or a complication of the disease which may have been triggered by the blood
transfusion.
There are also instances of delayed hemolytic transfusions. This occurs among patients
who had once received a transfusion that did not necessarily trigger the hemolytic reaction. A
second transfusion however is too much than the body can withstand and it therefore triggers a
hemolytic reaction. This kind of hemolytic transfusion is also found in deliveries where either
the mother or the child has antigen positive blood while the other does not have.
Transfusion reaction is used to evaluate the quality of care by examining the efficiency of
the nurses in conducting the blood transfusion. High cases of infusion transfusion due to clinical
errors can be used to indicate low quality of care in the hospital. This is due to decreased
competency levels as nurses are not keen enough to prevent errors of diagnosis and labelling of
blood samples and the patients (Ogrinc, Davies, Goodman, Batalden, Davidoff, & Stevens,
2015). Increase in such errors may also result to increase in other challenges as transfusion
reaction alone is able to cause a number of challenges to the patient. Transfusion reaction
resulting from clinical errors also shows that the health officers undermine the patient safety and
are not able to guarantee safe patient practices that prevents complication of already existing
conditions. Finally, transfusion reaction due to the presence of another disease also shows
insufficient prognosis or poor diagnosis. Poor diagnosis and prognosis is dangerous not only in

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blood transfusion but also in other diseases that may equally threaten the health of the individual
(Vidler, Gardner, Amenyah, Mijovic, & Thein, 2015).
According to Negi, Gaur, & Kaur, (2015) while transfusion reaction may not account for
many deaths and complications, errors in diagnosis account for many types of illnesses and
complications most of which develop as allergic reactions either to certain drugs or serious
infections. Errors in diagnosis also increases the likelihood of hospital readmissions up to about
40% argues Gurses, (2016) Errors in diagnosis can therefore be seen as threatening the patient
safety and quality of care offered in the hospital.
Summary of literature
According to Smeulers, Verweij, Maaskant, de Boer, Krediet, van Dijkum, & Vermeulen,
(2015), transfusion reaction is an example of a provider level indicator. This means that
transfusion reaction is one indicator that is not affected by the environment but by the quality of
service and the quality measures employed by the health care officers. The provider level
indicators consist of indicators that are deemed to be preventable. This makes it a good indicator
of both quality of health care and safety of the patient care.
Transfusion reaction as an indicator can therefore be used to improve the quality of care
in a hospital setting. This can be done in several ways for instance, nurses and doctors can be
urged to be keener in labelling and identification of blood samples, drugs and other materials.
Nurses can also change the model of care or the style of leadership in order to minimize the
errors that may arise from inefficiencies in the model or the style of leadership. The primary
mode of care is one of the most efficient models of care as nurses stay with patient around the
clock. It minimizes handling of the patient by too many nurses which in turn improves

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performance and efficiency Weinstock, Möhle, Dorn, Weisel, Höchsmann, Schrezenmeier, &
Kanz, (2015).
Lastly, nurses and doctors also need to focus more on patient satisfaction, other than
technical efficiency which aims at minimizing costs and maximizing profits. Patient satisfaction
refers to all those activities and incentives that are geared towards improving the quality of care
for the sake of the patients (Groene, 2018). This may include lowering costs, focusing more on
fulfilling patient rights, improving communication and proper record keeping among other
activities.
PDSA quality cycle
A plan to do study (PDSA) cycle is an important assessment tool that can be utilized to
help in identifying change. This is done through making a plan to investigate the phenomenon,
executing the plan, making observations and conclusions depending on the observations and the
final step is to decide the course of action based on the test results and conclusions. The PDSA
cycle is largely used in health care organizations due to the ease and effectiveness to determine
and improve various changes in health care such as improvement of quality, safety or
deterioration Taylor, McNicholas, Nicolay, Darzi, Bell, & Reed, (2014). The PDSA cycle is even
more relevant as it helps to offer solutions to the identified challenges. In this case, the PDSA
quality cycle will be employed to solve errors in clinical reasoning at the hospital.
In a day to day hospital environment, errors in clinical reasoning are almost inevitable.
These errors have various causes that have been attributed to them. Some of these causes include
pressure on time, complexity of various health conditions and the tendency of the human mind to
generalize or make assumptions in areas one is not sure about. Generalizations are common

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especially in the laboratory where there are conflicting values or misleading results. The
tendency of human beings to have self-fulfilling prophesies is also one of the causes of errors in
clinical reasoning (Oakley, Woods, Arnold, & Young, 2015).
In order to solve the errors in clinical reasoning therefore, it is necessary to use the PDSA
quality cycle as these errors lower the quality of health care and patient safety in the hospital.
The first stage is planning, it is important to make a plan on the intended purpose argues
Sherbourne, Aoki, Belin, Bromley, Chung, Dixon, & Khodyakov, (2017). This plan includes
making arrangements to find out the root cause of the problem. The plan may involve conducting
research in the form of direct/indirect observation, interviews and opinion polling. It is important
that the researcher to employ techniques that are most likely to give them the desired results.
The next stage is the do stage. At this stage, the nurse may conduct research on a single
isolated case with the aim of being able to determine the causes of the errors in clinical
reasoning. Data collected is recorded for analysis. In this case, it refers to finding the causes of
the errors in clinical reasoning. In addition to the ones highlighted above, one may also include
fatigue, ill health, old age and other human factors.
The third stage is the study stage. In this stage, one conducts a deep analysis on the
results obtained in the do stage. According to Montero, Moffatt, & Jarris, (2015), the aim of this
is to come up with possible solutions that can be used to address the identified challenge. For
instance, if it is identified that the main reason for the errors is fatigue, one may propose the
solution to be change in the number of working hours or addition of new workers into the
workforce. Alternatively, referring patients to other care facilities is also a way of dealing with a
large patient population.

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Finally, the last stage is the act stage. In this stage, the nurse or the researcher implements
the suggestions that have been identified in the study stage. This stage is also called the change
stage as this is the stage where all the plans are instituted. The plans are believed to help in
improving the quality of care and patient safety in improving by solving the identified challenge
with the already researched and analyzed solutions.
In conclusion, the PDSA quality improvement cycle is applicable over many wide topics.
For instance, with an indicator such as transfusion reaction, the PDSA improvement cycle can be
used to conduct research and identify the causes of the hemolytic reaction (Knudsen, Laursen,
Bartels, Johnsen, Ehlers, & Mainz, 2018). These may include errors in labeling of samples. The
model may then be utilized to propose a solution such as changing the model of care in order to
achieve improve the quality of care.

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