18.2.1 DECISION TO TRANSFUSE

The use of evidence based clinical guidelines minimises the adverse effects of transfusion (85). Clinical guidelines are systematically developed documents to assist physician and patient decisions about appropriate health care for specific clinical circumstances. Use of the term “evidence-based” in the context of clinical guidelines implies that the recommendations have been created using an unbiased and transparent process of systematically reviewing, appraising, and using the best clinical research findings. 
Inappropriate, unnecessary and non-evidence-based decisions to transfuse may result in more harm than benefit to a patient. Although traditionally not looked upon as a ‘‘classical’’ transfusion error, this inappropriate usage of blood may actually be the largest source of preventable error that would benefit from further systematic scrutiny. A patient succumbing to TRALI from an unnecessary transfusion of a unit of fresh-frozen plasma (FFP) should be considered a possible preventable transfusion error. In deciding to transfuse, failure to provide the transfusion laboratory with details regarding the patient’s transfusion history or special blood requirements can result in serious morbidity and even mortality. These important details include a previously detected alloantibody, requirements for washed units, leucoreduced or irradiated blood components. Conversely, hospital transfusion laboratories should also have a system for recording special needs for patients including significant alloantibodies and the need for irradiation. 
Piccin et al, has recently reported a review of TACO cases reported to the National Haemovigilance Office in Ireland(86). Between 2007 and 2010, a total of 99 TACO reactions were reported and in 19 (19%) of these reports, human error caused or contributed to the reaction. In seven of these cases, more than one human error was reported. These human errors are summarized as follows:
 
- 17 cases of failure to follow hospital policies regarding transfusion monitoring of vital signs and of fluid balance;
 
- Errors of communication and coordination of health care are common underlying causes of error. For example, components prescribed and transfused by two different doctors resulting in a patient receiving 6 RBC units instead of 3, failure to administer diuretics before transfusion, and failure to cancel prescription for RBCs that were subsequently transfused.
 
- Knowledge deficits on the part of clinical staff where there was a failure to assess the patient before transfusion or to recognize earlier symptoms of pending overload.
 
 
All of these human errors involved clinical staff and occurred in clinical areas. Four reports (21%) also identified system failures, such us organization culture issues that prevented junior clinical staff from questioning the requirement for transfusion and thus leading to an unnecessary RBC transfusion; another case where the patient developed a TACO and management priorities resulting in limited clinical supervision of inexperienced junior doctors.