Headnote
Abstract
Introduction: Blood transfusion is common, but transfusion reactions, often caused by human error, can be prevented. Nurse-led programs improve patiënt safety with safe nursing practices. This unprecedented study maps nursing care in blood transfusion, an underexplored theme in the literature. It aims to identify knowledge gaps and propose new approaches, contributingto nursing and otherfieldsof healthcare, promoting safe care standards and interdisciplinary practices for excellence in transfusion care. Objective: To map the scientific production related to nursing care for adults undergoing blood transfusion in the light of patiënt safety. Materials and Methods: This is a scoping review based on the JBI methodology, covering seven databases, following the checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Studies published from 2017 to 2024 were included; the descriptors 'nursing care' and 'blood transfusion' were used; 515 primary studies were initially included that covered nursing care for adult patients undergoing blood transfusion, in any language, with different methodological approaches. The review was registered on the Open Science Framework platform. Results: A total of 19 primary studies were selected. The most prevalent types of nursing care highlighted in this review are hand hygiëne, the use of per-sonal protective equipment, checking and verifying medical prescrip-tions, double-checking during blood collection and administration, monitoring vital signs, and advising patients on the signs and symp-toms of transfusion reactions. Conclusion: In the synthesis conducted, it is concluded the adoption of nursing care standards based on good practices is vital for effective patiënt safety and reduces the risks and complicationsassociated with blood transfusion procedures.
Keywords (Source: DeCS)
Blood safety; patiënt safety; nursing care; blood transfusion; evidencegaps.
Resumen
Introducción: la transfusión sanguínea es frecuente, pero las reac-ciones transfusionales, a menudo causadas por errores humanos, pueden prevenirse. Los programas dirigidos por profesionales de enfermería mejoran la seguridad de los pacientes con prácticas de enfermería seguras. Este estudio inédito mapea la atención de en-fermería en las hemotransfusiones, un tema poco explorado en la literatura. Pretende identifcar vacíos de conocimiento y proponer nuevos enfoques, contribuyendo a la enfermería y a otras áreas de la salud, promoviendo estándares de cuidados seguros y prácticas interdisciplinares para la excelencia en la atención transfusional. Objetivo: mapear la producción científca relacionada con los cui-dados de enfermería a adultos sometidos a hemotransfusión a la luz de la seguridad del paciente. Materiales y métodos: una revisión de alcance basada en la metodología del JBI, en siete bases de datos, siguiendo el checklist de los Preferred Reporting Items for Systema-tic Reviews and Meta-Analyses extension for Scoping Reviews. Se incluyeron estudios publicados entre 2017 y 2024; se utilizaron los descriptores Nursing Care y Blood Transfusion; se incluyeron ini-cialmente 515 estudios primarios que cubrían el tema de la atención de enfermería en pacientes adultos sometidos a transfusión sanguí-nea, en cualquier idioma, con diferentes enfoques metodológicos. Se registró la revisión en la plataforma Open Science Framework. Resultados: se seleccionaron 19 estudios primarios. Los tipos de cuidados de enfermería más prevalentes destacados en esta revi-sión fueron la higiene de las manos, el uso de equipos de protección individual, la comprobación y verifcación de las prescripciones mé-dicas, el doble control durante la extracción y administración de la sangre, la monitorización de los signos vitales y el asesoramiento a los pacientes sobre los signos y síntomas de las reacciones trans-fusionales. Conclusión: en este resumen, se puede concluir que la adopción de normas de cuidados de enfermería basadas en bue-nas prácticas es esencial para la seguridad efectiva del paciente y reduce los riesgos y complicaciones asociados al procedimiento de hemotransfusión.
Palabras clave (fuente DeCS)
Seguridad de la sangre; seguridad del paciente; atención de enfermería; transfusión sanguínea; lagunas en las evidencias.
Resumo
Introdução: A transfusão sanguínea é comum, mas reações trans-fusionais, muitas vezes causadas por erro humano, podem ser evi-táveis. Programas liderados por enfermeiros melhoram a seguran-ça do paciente com práticas de enfermagem seguras. Este estudo inédito mapeia os cuidados de enfermagem em hemotransfusão, tema pouco explorado na literatura. Visa identifcar lacunas de co-nhecimento e propor novas abordagens, contribuindo para a enfermagem e para outras áreas da saúde, promovendo padrões de cuidado seguros e práticas interdisciplinares para a excelência no atendimento transfusional. Objetivo: mapear a produção científca relacionada aos cuidados de enfermagem ao adulto submetido à hemotransfusão à luz da segurança do paciente. Materiais e mé-todos: revisão de escopo baseada na metodologia do JBI, em sete bases de dados, seguindo o checklist dos Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Foram incluídos estudos publicados de 2017 a 2024; uti-lizaram-se os descritores Nursing Care e Blood Transfusion; foram incluídos inicialmente 515 estudos primários que contemplavam a temática sobre os cuidados de enfermagem ao paciente adulto submetido à transfusão sanguínea, em qualquer idioma, com dife-rentes abordagens metodológicas. A revisão foi registrada na plata-forma Open Science Framework. Resultados: 19 estudos primários foram selecionados. Os cuidados de enfermagem mais prevalentes evidenciados nesta revisão são higienização das mãos, uso de equi-pamentos de proteção individual, verifcação e conferência da pres-crição médica, dupla verifcação durante a coleta e administração de sangue, monitoramento dos sinais vitais, orientação ao paciente sobre sinais e sintomas de reações transfusionais. Conclusão: Na síntese realizada, conclui-se que a adoção de padrões de cuidados de enfermagem alicerçados nas boas práticas é essencial para a segurança efetiva do paciente e reduz os riscos e as complicações associados ao procedimento de hemotransfusão.
Palavras-chave (Fonte DeCS)
Segurança do sangue; segurança do paciente; cuidados de enfermagem; transfusão de sangue; lacunas de evidências.
Introduction
Blood transfusion is a common treatment used in clinical settings. It is a therapeutic procedure characterized by the use of blood components for the treatment of various pathologies (1). This is a globally acceptable approach for a range of clinical, surgical, and emergency treatments, as it has shown remarkable efficacy when used adequately. However, this procedure is not exemptfrom risks, mostly related to the recipiënt of the blood components (1).
Although all the necessary precautions are foliowed, transfusion procedures have a great potential for manifesting risks, such as infectious diseases, immunosuppression, and alloimmunization, which means that its practice is restricted to situations where there is a specific clinical recommendation and in the absence of other therapeutic resources (2).
As a prerogative, transfusion can be recommended in situations such as in adults with acute hemorrhage with an Hb< 8.0 g/dl; normovol-emic patients who are going to undergo orthopedie surgery or are suffering from gastrointestinal bleeding with an Hb< 7-5g/dl, as a form of prevention; and intensive care unit (ICU) patients usingcar-diopulmonary bypass, victims of acute neurological injury, or on-co-hematological patients (2).
However, hemotransfusion simultaneously has proven beneficial when administered adequately, such as oxygen supply, correction of coagulopathies, control of critical bleeding, and reduction of symptoms associated with anemia, as well as being essential in procedures such as surgeries, treatments, and chemotherapy, which cannot be performed safely without its application (3).
In the Brazilian context, the National Health Surveillance Agen-cy {Agenda Nacional de Vigilancia Sanitdria - Anvisa) reports that 84.21% of transfusion reactions reported are mild and immediate (4). This scenario is validated by the epidemiological index, since febrile hemolytic reactions, infection, acute lung lesions related to transfusion, and graft-host disease are some of the complications stemming from transfusion reactions (5).
Furthermore, transfusion reactions can be avoided, as numerous transfusion-related events are caused by human error (5, 6). The most common errors are incorrect identification of the recipiënt and incorrect sample labeling at the time of blood transfusion. These are responsible for 80% of reported events and preventing them could avert 45% of deaths (7, 8).
Measures that promote a culture and infrastructure that reduce risks in healthcare are part of patiënt safety. Despite these efforts, approximately one in ten patients in rich countries and one in four in poor countries suffer avoidable errors, increasing healthcare costs and causing approximately 2.6 million deaths (9). In this sense, hemotherapy procedures should be conducted by trained nurs-es, as the transfusion of blood and blood components requires knowledge entailing its application, risk management, and timely measures to effectively intervene in possible complications (10). These professionals have an important role in the safe conduct of hemotherapy, detecting signs and symptoms of reactions in the various stages of the transfusion chain (11).
Consideringthe physical proximity that nurses haveto patients and the care they provide, which must be effective and safe, these professionals need accurate knowledge and should receive athorough education on the transfusion processwhilestill com-pleting their undergraduate studies to ensure safe patiënt care. Thus, transfusion safety is improved by measures designed to reduce the probability of human error. This implies that the use of educational techniques such as clinical simulationsto achieve this goal can be effective measures even employed during undergraduate training. The implementation of plans to improve healthcare safety is included in the Global Action Plan for Patiënt Safety 2021-2030 (12,13).
With the implementation of patiënt safety measures, the goal is to reduce the risk of harm related to the healthcare provided. Consideringthe importanceofthistheme, the World Health Or-ganization established the Global Alliance for Patiënt Safety in 2004, setting three global challenges: Safe surgeries, hand hygiëne, and harm-free medication. Blood transfusion, just as any other health procedure, offers benefits, but is not exempt from risks that can befatal. It isthereforenecessarytoadopt integrat-ed measures to ensure safe care inthissettingtoavoid partial or fatal injuries. Under these circumstances, patiënt safety consists of a set of practices that enable the creation of a culture, struc-ture, processes, conduct, and technologies to reduce the risks related to healthcare, as well as consolidate their impact in the event of complications.
Despite the efforts directed towards the development of strat-egies to help improve patiënt safety, estimates indicate that, in developed countries, one in ten patients is subject to preventable errors related to healthcare, and this figure is higher in underde-veloped or developing countries, where one in four patients is subject tothem (9).
In this context, nursing bears a strategie role in providing care and managing risks related to the transfusion process. The inter-ventions performed by the nursing team aim to prevent complications and adverse reactions, thus ensuring the patient's safety and well-being. Nursing care is implemented before, during, and after transfusion. Therefore, due to their role in the transfusion process, nurses' knowledge and practices regarding blood transfusion contribute to patiënt safety and improved care (14).
The provision of safe patiënt care relies on the strategies adopted by the nursingteam in the service in question. The implementation of protocols and instruments is essential for providing safe care. Regarding safe transfusion care, Anvisa has implemented Colle-giate Board Resolution (Resolugao da Diretoria Colegiada - RDC) No. 153/2004, which establishes a technical regulation for hemothera-py practice, covering procedures from the collection to the use of blood and blood components in human beings. Documents such as this enable the development of systematized care, contributing to the provision of safe care (15).
In lightoftheneedto promote research and effective, safe care that contributes to patiënt safety, this scoping review is justified as it al-lows mapping nursing care for adultsundergoing blood transfusion. It is believed that this research will helpto identifygapsand suggest ways of developing safe care standards and advancements in the models already outlined in the literature.
Therefore, this review aims to map the scientific production related to nursing care for adults undergoing blood transfusion in the light of patiënt safety.
Materials and Methods
This is a scoping review, which was created in line with the method-ology developed by thejoanna Briggs Institute Reviewer's Manual for Scoping Reviews and foliowed the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses exten-sion for Scoping Reviews Checklist (Prisma-ScR). This review was registered on the Open Science Framework Registries platform, un-derthe identifier https://0sf.i0/7cqjs/ (16,17).
To map the publication landscape on the theme, especially to iden-tify similar reviews or protocols, a search was conducted on the fol-lowing platforms: Open Science Framework (OSF); The Cochrane Library; JBI Clinical Online Network of Evidence for Care and Ther-apeutics (ConNECT+); Database of Abstracts of Reviews of Effects (Dare); and Prospective Register of Systematic Reviews (Prospero). Afterthe searches, the absence of similar materials wasconfirmed. Thistypeofstudyaimstoidentify, map, and synthesize the evidence and gaps in the existing knowledge in a given field of research. This process preserves methodological rigor through the following out-line: identification of the research question; identification of relevant studies; study selection; data analysis and extraction; and data synthesis and presentation (16,17).
The research question was devised usingthe core elements of the PCCacronym (Population-Concept-Context [17]), in which 'P' (pop-ulation) represents hospitalized adult patients; 'C' (concept), nursing care; and 'C (context), patients undergoing blood transfusion. In light of this, the following question was drawn: Which forms of nursing care are provided to hospitalized adult patients under-going blood transfusion?
All types of studies and publications were included in this review, that is, thosethat used any type of methodological approach and design. Studies that did not present nursing care for adults un-dergoing blood transfusion were excluded.
The searches were conducted in March and April 2024 in the following databases: Scopus, Web of Science, PubMed/Medline, Latin American and Caribbean Health Sciences Literature (Li-lacs), Cumulative Index to Nursing and Allied Health Literature (Cinahl), BDEnf, and IBECS. In addition, a search for publications was conducted on Google Scholar.
A survey of the free and controlled vocabularies used in publications written on the proposed theme was conducted, which were considered when designing the search strategies for the publications, as shown in Table 1; these were adapted to each database, usingthe Boolean operator AND. Searches were limit-ed to materials published from 2017 to March 15,2024. The peri-od was selected based on relevant advances in hemotransfusion practices identified in 2017, such as the dissemination of care (14).
The following eligibility criteria were considered: Primary studies whose authors addressed nursing care for adult patients un-dergoing blood transfusion; published in Portuguese, English, or Spanish; from January 2017 to March 2024. The following were excluded from the review sample: Descriptions of integrative, systematic literature reviewand/or meta-analysis studies, as well as reflection articles and articles that addressed the theme but did not describe the care provided. The time frame was estab-lishedto limit the scope of the reviewtoamanageable numberof studies to ensure the quality and relevance of the data analyzed.
The Mendeley reference manager was used to eliminate duplicates of the publications exported from the six databases, and the Rayyan web application was used to assist in the organization and selection of articles; in addition, the searches were conducted from November 2023 to March 2024.
Forthestudy selection process,two independent reviewers examined the titles and abstracts. The full text was selected for analysis when there were doubts concerning the relevance of a study based on its abstract. The full articles were randomly assigned to each reviewer. In addition, two reviewers conducted an independent review of the full text of the articles todetermine whetherthey met the inclusion criteria and answeredthecorequestion of the review. In case of disagree-ment, a third reviewer was consulted to delimit the inclusion of the study. The authors of this manuscript were reviewers for all stages.
To extract the content, an instrument structured bythe authors was used, considering the following variables: Article identification (ID), year, publication country, type of study, level of evidenceclassified as described by Melnyk and Fineout-Overholt (18), classified from one (I) to seven (VII) levels of nursing care; and other relevant situations among the selected studies. The reviewers mapped the data inde-pendently, discussed the results, and continually updated the data mappingform in an interactive process, in line withJBI guidelines (17).
The research was based exclusively on public domain data, elimi-nating the need for submission to a research ethics committee, in compliance with Resolution 510/2017. It should be noted that copyright has been duly preserved through adequate citation and bib-liographic reference.
Results
The flowchart of the selection process for the primary studies in-cluded in the scoping review is presented in Figure 1. Therefore, of the 515 publications found in the databases, after applying the eligi-bility criteria, 26 primary studies were selected to be read in full and 19 comprised the review sample.
Amongthe countries in which the studies were conducted, this article found that most of the published studies were from Brazil, with a total of six (33.3%) studies, with a less dense distribution amongthe other countries analyzed, as shown in the thematic map in Figure 2, which is a proportional choropleth representation of the distribution of articles.
The articles included in this review were from 10 countries, includ-ing Brazil (n = 6), Japan (n = 1), Iran (n = 1), India (n = 1), the United States (n = 5), China (n = 1), Mexico (n = 1), Turkey (n = 1), Ghana (n = 1), and Egypt (n = 1). Most of the studies included were cross-sectional (n = 9)> qualitative (n = 3), experience report (n = 1), methodological (n = 1), observational (n = 3), pilot (n = 1), and exploratory (n = 1).
In general, the nursing care presented in this review was provided in a hospital setting and one instance took place in a hemotherapy reference unit, as shown in Table 2. The studies cited trauma, emer-gency, medical-surgical wards, ICU, and oncology units as hospital-ization sites.
The results show that the care mapped is related to the pre-, intra-, and post-transfusion phases. In addition, simple precautions, such as hand hygiëne, are essential for ensuring safe transfusion care. Table 3 shows the main nursing care associated with adult patients undergoing blood transfusion, according to the data collected in thissynthesis.
Discussion
This review mapped primary evidence that showed great thematic relevance, but which is still underexplored in the literature. It summarized several types of evidence related to nursing care for adult patients undergoing hemotransfusion, which should be implemented in care to improve effective and safe care. These findings highlight the need for professionals to adhere togood practices.
Among the various types of care provided by the nursing team to patients undergoing blood transfusion, after analyzingthe se-lected studies, it was found that the most common are checking vital signs, double-checking, monitoring the patiënt during the transfusion, and interrupting the transfusion immediately in the event of a transfusion reaction. In total, 10 studies mentioned "check vital signs," which corresponds to 52.6%; the second most common nursing care was "monitor the patiënt during the transfusion," with 31.5%. Other precautions mentioned were: "perform a double-check," and "interrupt the transfusion immediately in the event of a transfusion reaction," both representing 26.3%; "avoid administering medications through the same ac-cess," "warm the blood bag before infusion," and "advise the pa-tient/family on the benefits and associated risks of blood transfusion and transfusion reactions" represented 15.7%; "check and verify the medical prescription," "administer pre-transfusion blood medication," and "use the adequate aseptic technique in administration and preparation" represented 10.5%; "use per-sonal protective equipment (gloves and masks)" and "perform hand hygiëne" represented 5.2%.
It was found that checking vital signs, double-checking, monitoring the patiënt during the transfusion and interrupting the transfusion immediately if the patiënt experiences a transfusion reaction are important tasks to ensure safe, effective, and quality nursing care in terms of patiënt safety (19,21,29,30).
Hand hygiëne is an essential, simple, effective, and low-cost meth-od that is widely used in the healthcare sector, including nursing. lts importance for patiënt safety is undeniable, and it is important for preventing infections (37). Adherence to this practice can vary due to various factors, such as risk perception, organizational culture, supervision, and availability of resources. It is crucial to promote and emphasize the importance of hand hygiëne to ensure patiënt safety and well-being (38).
In this review, this type of care was only highlighted by one study, representing 5.2% of the total. Similarly, a study that assessed the administration of medication by nursing students and another that assessed the knowledge and practice of nurses and students showed the importance of performingthe hand hygiëne procedure and suggested increasing strategies for greater adherence to this practice (39-41). This presents an opportunity to improve patiënt safety during transfusions and to prevent patiënt complications.
The present study highlights the importance of nursing care during blood transfusions, emphasizing the need for rigorous practices to ensure patiënt safety. While some studies emphasize hand hygiëne, detailed checking of patiënt data, and constant monitoring during transfusion, others highlight the checking process by two professionals at different stages of the process, including sample collec-tion and blood administration. Similarly, some studies highlight the importance of double-checking, the use of personal protective equipment, and careful monitoring of the patient's vital signs, all of which contribute to preventing errors and promoting safety during blood transfusion (42, 43). However, there is still a need for studies that assess the establishment of these precautions.
The administration of any medication into the same venous access used for transfusions can resultin serious complications for the patiënt, including death (44). Two studies highlighted the importance ofavoidingthesimultaneous administration of medications into the same venous access used for transfusions, a precaution presented in 10.5% of the studies (45,46). These results raise a significant concern due to the crucial importance of this care in patiënt safety (47).
Therefore, working jointly with risk managers to analyze transfusion practices raises awareness and leads to the implementation of corrective measures. In addition, studies suggest the need for training as, despitethe regular training, there are malpracticesthat need to be addressed through periodic training to raise the culture of safe care (48,49).
The studies used to develop the review address issues related to the transfusion process and show a range of nursing interventions tar-geting blood transfusion. Checking vital signs (blood pressure, heart rate, respiratory rate, and temperature) includes the pre-, trans-, and post-transfusion periods since the pre-transfusion period begins 10 minutes before the infusion (50). Last but not least, it isworth highlightingtheimportanceof immediately interrupting the transfusion at the sign of transfusion reactions (51).
The literature covering the standardization of nursing care for adult patients undergoing blood transfusion is limited. In Bra-zil, although there is legislation defining the roles of the nursing team and Standard operating procedures in hospitals, these materials are not widely disseminated in the relevant literature. The studies included in this review report similar barriers in other contexts.
The scoping review on nursing care for adult patients undergoing blood transfusion shows that, despite the existence of widely accepted guidelines for transfusion practices, there is a significant gap in the development of specific protocols that ensure the safety and quality of care. The development of such protocols is essential for achieving international transfusion safety targets, which aim to minimize the risks associated with transfusions, such as adverse reactions and infections.
The studies analyzed highlight several aspects of nursing care, including identifyingthe patiënt, checking blood type, monitor-ing vital signs, and monitoring for possible adverse reactions. However, the regulation and standardization of procedures warrant more attention, as the lack of clear regulations can lead to variability in practices and subsequent errors. Adequate training for nursing professionals, efficiënt adverse event reporting systems, and strict informed consent protocols are crucial to protect patients and ensure that care is in line with international best practices.
In terms of the limitations of the study, the scarcity of materials that explicitly address nursing care for adults undergoing blood transfusion stands out as alimiting factor for the progress of evi-dence-based discussions on the theme. Despite mapping nursing care in blood transfusion, this study has limitations. The preva-lence of Brazilian research, methodological heterogeneity, and the lack of quantitative and cost-effectiveness analyses reduce thegeneralizabilityand robustnessoftheresults. Therestriction to adult patients in hospitals limits itsapplicability, whilethe lack of standardization in care and data on training are relevant gaps. Future studies should address these issues with cost analyses and standardized protocols for greater transfusion safety.
The contributions of this study to the field of healthcare, espe-cially nursing, are based on mapping nursing care in the context of patiënt safety regarding transfusion. In addition, it provides solid evidence that can support the development of protocols for the implementation of a transfusion safety policy.
The findings of this review can be integrated into daily clinical prac-tice by adopting evidence-based protocols that improve transfu-sion safety. Continuous training for nursing personnel, the use of technologies for identity verification and blood component track-ing, aswellastheimplementation of protocols for rapid response to adverse reactions, are essential measures. Strict monitoring of vital signs and double-checking during transfusion reduce risks, while patiënt and family education contributes to the early recognition of complications. These strategies improve the culture of patiënt safety, promoting more effective care in line with the best practices in transfusion nursing.
Conclusion
The present study mapped nursing care for hospitalized patients undergoing blood transfusion. In this context, this research contributes significantly to the knowledge field by highlighting safe be-haviors that improve the Standard of care for patients undergoing transfusion therapy.
The main precautions mapped in the present study were checking vital signs, double-checking, monitoring the patiënt during the transfusion, and interrupting the transfusion immediately ifthe patiënt hasa transfusion reaction. Inaddition.the needtoworkonthe standardized development of techniques such as hand hygiëne as a safety culture in transfusion assistance was exposed.
Based on the scoping review conducted, it can be concluded that there is a vast field to be explored to create protocols and practices that meet international transfusion safety culture targets.
Conflict of interest
The authors declare no conflict of interest.
References
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