ABSTRACT
Blood transfusion saves lives but can result in poor client
outcome when it is associated with errors. This study aimed at examining the
knowledge of blood transfusion and practice errors among nurses in the Cape
Coast Teaching Hospital. The study utilized a descriptive cross-sectional
design approach using 140 registered nurses who were selected purposively. A
modified Routine Blood Transfusion Knowledge Questionnaire (RBTKQ) was used to
collect information in two sections. First part on demographic data and second
part on knowledge and practice errors which were structured along a three-point
Likert scale. Data was analysed with SPSS version 20, the binary logistic
regression analysis was employed and all inferences were drawn at 5%
significance level. Results showed that nurses have higher knowledge in the
four phases of blood transfusion practices as they scored overall averages of
2.79, 2.80, 2.64 and 2.83 out of 3.0 for Phases I, II, III and IV,
respectively. Although, majority of the nurses (72.0%) acknowledged they have
not received any official training on blood transfusion since commencement of
clinical work. A z-value of 165.29 and p < .05 indicated that there was
a significant difference in the knowledge level of the nurses on the four
phases of the procedure. On commonest errors, 40 (28.6%) nurses reported that
they sometimes forgot to check vital signs throughout the transfusion process.
This study concludes that nurses have very good knowledge on blood transfusion
process but some practice errors exist that put patients at risk. Periodic
training and auditing of the transfusion process is therefore recommended.
CHAPTER ONE
INTRODUCTION
Background to the Study
Blood transfusion is the transfer of blood or a blood
component from one person (a donor) to another (a recipient). Transfusions are given
to improve the blood’s ability to increase its oxygen carrying capacity,
restore any blood deficit, improve immunity, and correct clotting problems.
Depending on the reason for the transfusion, a physician may order whole blood
or a blood component, such as red blood cells, platelets, blood clotting
factors, fresh frozen plasma (the liquid part of blood), or white blood cells
(Shander, & Popovsky, 2005). Demand for blood is driven by an array of
factors that include obstetric hemorrhage, road traffic accidents, armed
conflict, sickle cell disease and childhood anemia, malnutrition, HIV, malaria,
and parasitic infections (Tapko, Mainuka & Diarra-Nama, 2006).
Every second, someone in the world needs blood. In every
country, surgery, trauma, severe anaemia and complications of pregnancy are
among the clinical conditions that demand blood transfusion (World Health
Organization [WHO], 2006). The WHO report on blood transfusion safety found
that the pattern of blood usage is very different in many countries with a much
greater proportion of transfusions being given to women with obstetric
emergencies and children suffering from severe anaemia, often resulting from
malaria and malnutrition. It is estimated the use of red blood cell transfusion
in developing countries as pregnancy-related 37%, children 14%, surgery 12%,
trauma 18% and medical 19%. This is in sharp contrast to red blood cell
transfusion in the developed countries where red blood cell is used for purposes of complicated procedures such as open-heart
surgery, organ transplantation and other medical conditions such as leukaemia
and thassalaemia with pregnancy-related (6%) and child anaemia (3%) been the
least for red blood cell transfusion (Cable, Fatemeh & Edwards, 2007). A
closer look at these findings from the World Health Organization (WHO) report
suggest that blood transfusion are given in developing countries to treat basic
conditions to avert mortalities that would otherwise happen in the advance countries.
The above findings are agree with a research finding from
another studies from WHO, The United Nations Children's Fund (UNICEF), The
United Nations Population Fund (UNFPA) and The World Bank (2012), which stated
that , each year, an estimated 287,000 women die worldwide from complications
related to pregnancy and childbirth. More than half of these maternal deaths
(56%) occur in Sub-Saharan Africa with haemorrhage (severe bleeding) as the
leading cause. Therefore, among other strategies to prevent maternal deaths
from haemorrhage, child anaemia and other blood transfusion driven conditions,
the WHO, UNICEF, UNFPA and the World Bank states that it is important to make
available rapid access to adequate blood and highly knowledgeable personnel to
safely administer blood. Whatever the degree of development of the health care
system, blood transfusion is the only choice for survival for many patients and
this is where the essence of nurses’ knowledge and practice of blood
transfusion is imminent.
Blood transfusion is usually a life-saving component of
health care systems. Nevertheless, it can also be a quick and easy method of
exposing patients to risks, particularly the transmission of
infectious agents to recipients. Despite improvements in the safety of
transfusion services worldwide the procedure still subject patients to many
risks. Lee (2003), reported on a study of the differences between clinicians’
and laypersons’ perceptions of the risks involved in blood transfusion. He
found that clinicians’ concerns revolve around the appropriateness of
transfusion as a treatment and its risks, administration, and costs; patients’
concerns often centre on transmissible disease and comfort. Transfusion of
blood saves life. An error in blood transfusion, at the same time, takes life.
Clinical demand for blood is perennial and transfusion errors are must be
accountable. This accountability of transfusion errors comes to light with the
numerous reports on total blood transfusion errors. The discovery that HIV
could be transmitted by blood transfusion in 1982 has given rise to strict
regulations on blood donation and screening procedures. Apart from HIV, HBV and
HCV risks have also been well addressed in blood transfusion process.
The blood transfusion process is manned by a
multidisciplinary healthcare team which include nurses. Although the decision
to transfuse rests with the physician, the actual transfusion is conducted
entirely by the nurse who is at the point-of-care and therefore has an
essential role in patient safety during a blood transfusion. Nurses have an
opportunity to provide essential contributions to the national transfusion
safety initiatives and to nursing science by conducting research that is
focused on the gaps in transfusion knowledge, surveillance, and reporting
transfusion adverse events. Blood transfusion procedure lies largely in the
domain of nursing practice. Bishop (2008) indicated that the transfusion
process is composed of five interrelated phase; four of which are relevant to routine nursing
practice, such as, patient preparation before blood bag collection, blood pack
collection, pre and post transfusion nursing activities and where the safety of
blood transfusion is, amongst others, dependent on nurses' knowledge and
skills.
A lack of awareness of good transfusion practice has been
identified as a reason for poor compliance (Parris, 2007). Hijji (2010)
highlighted problems associated with Nurses’ blood transfusion practice and
adherence to recommendations. According to Hijji, blood transfusion errors
often include administration of blood to wrong recipient, phlebotomy errors
& blood bank errors including testing of wrong specimen. According to
Linden (2000), the most important of all those errors has been the failure to
detect at the bedside before transfusion of the blood unit .This is where
nursing action is independent of any member within the multidisciplinary team.
Therefore an error committed during this stage is largely a nursing error
though the decision to transfuse a patient was initiated and prescribed by the
physician. Nurses are responsible for the final bedside check before
transfusion and therefore have the opportunity to prevent a mis-transfusion (Mole,
2007). Deficiencies in the knowledge of blood transfusion can adversely
affect patient safety (Gallagher-Swann, 2011). Blood transfusion is a highly
effective and potentially life-saving treatment for many patients (Bradbury
& Cruickshank, 2000) and an essential component of modern health care. Red
cell transfusions are the backbone of blood transfusion therapy as they account
for the majority of components issued to patients (Taylor et al., 2010).
Surprisingly, transfusions of blood products, a practice which is intended to
save life, have been found to be associated with several complications, many of
which can be grouped as immunological or infectious. There is also increasing focus
on complications arising directly or indirectly from potential quality
degradation during storage (Wang, 2009).
Improper identification of patient as the main cause of
mistransfusion resulting in significant transfusion mortality may indicate
similar lack of knowledge (Myhre & McRuer, 2000). Lack of knowledge of
various aspects of blood transfusion by clinical staff, including nurses,
continues to be a real threat to patient safety (Taylor et al., 2010). For
example, errors in practice involving remote checks at nurses' stations
(Whitehead et al., 2003) may indicate that nurses are unaware that such checks
serve no purpose; they detract from performing proper bedside identification of
patient, and contribute to mistransfusion (Whitehead et al.). Mistakes in blood
transfusion and insufficient control of patients who receive blood during the
transfusion are among causes of death for such patients (Clark et al., 2001).
Since there is no substituting product for human blood, the need for blood
transfusion is still continuing.
Despite decades of nurses’ involvement with blood
transfusions, there is scant research to describe the practice of nurses as it
relates to blood transfusions (Fitzgerald, Hodgkinson, & Doughty, 2000).
The overwhelming majority of articles in the nursing literature that focus on
blood transfusion described case studies and provided education on recognizing
transfusion reactions, but there are only limited reports of research involving
nurses’ knowledge on blood transfusions. It is quiet surprising to note that
evidence used to guide blood transfusion practices in Africa has almost
exclusively been generated by wealthy countries in Europe and North America.
This trend is often inappropriate for low-income countries such as Ghana
yet research from within Africa about nurses’ knowledge on blood transfusion
and practice is seriously lacking. It is against this background that this
study was conducted.
Statement of the Problem
Adequate knowledge and proper practice of blood transfusion
are essential elements in modern clinical therapy. In a situation where
practice is mostly associated with error then the knowledge underpinning the
practice for the therapy has to be investigated. Rowe, (2000), revealed that
most published guidelines highlight that most serious transfusion complications
occur within the first fifteen minutes of transfusion. Therefore, a close
monitoring has been recommended before and fifteen minutes after commencement
of each unit of blood. The guidelines also recommend careful monitoring in the
areas of sample collection, preadministration checking to avoid adverse
reactions (Hainsworth, 2000).The above practice activities are all within the
time frame of nursing care in the blood transfusion process.
The practice of blood transfusion has evolved as therapy for
many patients and still continues to serve as the only hope for the survival of
those who require blood to live. Despite its existence for many decades in
Ghana’s health care system, research in the area of nurses’ knowledge that
underpins their practice of blood transfusion is very scanty. The justification
for this study is the paucity of nursing research in Ghana on blood transfusion
knowledge and practices, the national focus on transfusion safety including
adverse event reporting, and the emerging innovations in technology that have
the potential to enhance transfusion safety. Although many advances in donor-screening and blood testing have made Ghana blood supply very
safe, recommendations for further improvements in transfusion safety
consistently point to a safety-gap in the administration process, a process
that is primarily within the domain of nursing.
Thomas and Hannon (2010) linked the national focus to improve
transfusion safety in Ghana with the need to address the knowledge and
performance gaps of the bedside transfusionist. However, a description of Ghana
nurses’ preparation and practices with blood transfusions is lacking. Research
is needed to address this important clinical issue to validate or refute the
findings of quality reports on nurses’ transfusion practices which has
generated much debate.
It has been shown that errors associated with blood transfusions
in which nursing failure was often identified as the source of error was
recognized by (Wilkinson & Wilkinson, 2001, Heddle et al., 2012).
Additionally nurses’ lack of familiarity with the patient and language barriers
and lack of compliance with recommended practices promoted error (Dzik et al.,
2003 & Hyson, 2009). Most of these findings were generated by individuals
outside Ghana .However researching coming from within Ghana on errors nurses
commit and the reasons for the occurrence of these are lacking. Therefore the
purpose of this study was to examine the knowledge and practice errors among
Ghanaian nurses on blood transfusion processes.
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