Healthcare Inspection – Alleged Unsafe Blood Transfusion Practices, Battle Creek VA Medical Center, Battle Creek, Michigan

OIG conducted an inspection in response to a complainant’s allegations received in 2014 about unsafe blood transfusion practices at the Battle Creek VA Medical Center (BCVAMC) in Battle Creek, MI. The complainant alleged that a patient experienced an adverse reaction because of a BCVAMC hospitalist’s unsafe transfusion practices. We substantiated that a BCVAMC hospitalist engaged in unsafe packed red blood cell transfusion practices, which resulted in a patient’s adverse reaction. The patient’s pre-transfusion medical issues indicated that the hospitalist should have reassessed the need to transfuse 3 units of packed red blood cells and monitored the patient’s clinical status, including hemoglobin levels, more closely. The increase in blood volume from 3 units of PRBCs contributed to the patient experiencing a potentially life threatening adverse reaction due to circulatory overload. A lack of guidance in the BCVAMC policy, which did not support recommended standards issued by AABB (previously known as American Association of Blood Banks) for single unit transfusions, likely contributed to the hospitalist’s unsafe transfusion practices. Although not directly related to this patient’s case, unit staff identified communication barriers that may have affected professional clinical collaboration. BCVAMC policy requires providers report blood transfusion related adverse reactions to the Blood Usage Review Committee to help prevent similar adverse reactions from occurring in the future. Providers did not report this patient’s adverse reaction and the Blood Usage Review Committee did not analyze the circumstances surrounding the event. The committee Transfusion Officer was the physician ordering and supervising the majority of transfusions, presenting a potential conflict of interest between committee responsibilities and professional responsibilities. We also found that the Peer Review Committee did not follow VHA policy regarding documentation of committee recommendations for actions and follow-up by supervisors. We recommended that BCVAMC managers update the blood transfusion policy to align with AABB guidelines, ensure providers follow policy to report transfusion adverse reactions, and ensure the Blood Usage Review Committee Transfusion Officer has no conflict of interest between committee and professional responsibilities. We also recommended that the Peer Review Committee comply with VHA policy and document committee action recommendations and supervisory follow-up.