Table 1 Root cause analysis of events and its application to understanding this case

Communication problems

The blood salvaged during operation of Patient Y was not communicated  within the Cardiovascular Surgery department, Thoracic surgery department and among the nurses.

Most of them were unaware that Patient Y's blood was being stored postoperatively.

Errors occurred in perception of the risks and the cognition regarding how to avoid this error.

Patient Y's blood was not discarded on POD 1 as hospital policies dictate, nor was its presence shared among the nurses or even within the Cardiovascular Surgery department.

Inadequate information flow

Instructions for blood salvaging were not clearly communicated either verbally or in writing.

Nurses did not communicate with other nurses or physicians about their concerns regarding Patient Y's condition and questions regarding blood salvage protocols.

Human factors problems

Since collected blood devices were not equipped with a dedicated label, the patient's name was written directly on the red transfusion bag with a black magic marker. In addition to this, Nurse B could not recognize that the blood was from the wrong patient because the intensive care unit in the evening was dimly lit and the visibility was poor.

Nurse A, nurse in charge of Patient X Nurse B, the nurse in charge of Patient Y, to retrieve the blood in the cold storage, and was in a hurry because the patient's condition was unstable.

Patient-related issues

The patient was transferred to the ICU after a lengthy surgery, and their blood pressure was unstable.

Organizational transfer of knowledge

Nurse B did not know that the Intensive Care Unit had two cold refrigerators for storing blood.

Staffing patterns/work flow

The reason for this is that the intensive care unit was always busy, and the duties of the lead nurse were shared among several staff members.

The division of duties was the reason why labels were not applied, blood was not checked per hospital policies, and entries were not made in the logbook, nor was their absence noticed.

However, if the patient waunt stable, and providers had more time to check the blood, they could have correctly identifred the error and followed the  hospital policy.

Multiple healthcare provider teams were involved in the care of the patents, which also contributed to the communication challenges,

Technical failures

Both the physicians and nurses on site assumed that the only blood collected was from Patient X. They did not know that Patient Y's blood was stored. Therefore, they connected the Patient Y blood to Patient X's IV line, and administered it without doing the necessary checks.

Inadequate policies and procedures

The Surgery department did not issue an order to discard the blood on the following day. This was due to the lack of a written procedure and the unfamiliarity of the Thoracic surgeons with ABS hospital policy.

Intraoperative salvaged blood should have been placed in a dedciated basket with a note attached with the patient's name and ID, and placed in cold storage.

The blood in the cold storage was supposed to be checked twice a day by the lead nurse and recorded in the management log. However, there was no record of these activities.

It is against hospital policy to salvage blood products in cold storage where the temperature is controlled by the Blood Transfusion Service.

The Blood Transfusion Service was unaware that intraoperative blood collections were kept away from patients and stored in cold storage. Therefore, the operating room and intensive care unit were unable to assess and verify  the blood collection procedures of the operating room and intensive care unit.

The Blood Transfusion department could not question the blood salvage procedures in the operating room and intensive care unit because they were unaware that intraoperative salvaged blood were kept away from the patient and stored in cold storage.

The central operating department and intensive care units were in a position to correct such misuse, but they did not have written procedures for handling intraoperative blood collection and did not exercise proper governance and oversight.

The basket containing Patient Y's blood did not have a note attached with the name and ID, and the pack did not have a dedicated label.