대한수혈학회지 : 제 26 권제 3 호, 2015 The Korean Journal of Blood Transfusion Vol. 26, No. 3, 266-272, December 2015 http://dx.doi.org/10.17945/kjbt.2015.26.3.266 pissn 1226-9336 eissn 2383-6881 Original Article 수혈전혈액확인에환자참여의경험 : 단일기관연구 김보람 1 ㆍ김경희 1 ㆍ임현호 1 ㆍ김병권 2 ㆍ강명구 3 ㆍ차태옥 4 동아대학교의과대학진단검사의학교실 1, 예방의학교실 2, 이비인후과학교실 3, 동아대학교병원의료질향상관리과 4 An Experience of Patient Involvement in the Pre-Transfusion Checking Process: A Single Center Study Bo-Ram Kim 1, Kyeong-Hee Kim 1, Hyeon-Ho Lim 1, Byoung-Gwon Kim 2, Myung-Koo Kang 3, Tea Ok Cha 4 Departments of Laboratory Medicine 1, Preventive Medicine 2, Otorhinolaryngology-Head and Neck Surgery 3, Dong-A University College of Medicine, Department of Quality Improvement, Dong-A University Hospital 4, Busan, Korea. Background: Correct transfusion of blood product to the right patient requires multiple processes. Errors occurring in the pre-transfusion checking step can result in a serious incident. The role of patients in the safe blood transfusion practice has been investigated. Methods: We have adopted patient involvement in bedside checking using patient s signature since 2010. We conducted a retrospective review of transfusion medical records during January 2013. The signatures of doctors, nurses, and patients were audited and the reasons for omitting patient s signature were examined. Results: The practice of patient s signature was performed after the problems of procedures were improved. A total of 4697 blood products for 576 patients were issued. The first transfused products were 426 units of RBC (74.0%), 56 units of platelet (9.7%), and 34 units of fresh frozen plasma (5.9%). Completion of patient s signature was observed in 336 patients (63.5%). The reason for omitting patient s signature was operation (104, 18.1%), unclear consciousness or sedation (75, 13.0%), and neonate or infancy (7, 1.2%). Conclusion: Patient involvement in the pre-transfusion checking process by writing down the patient s own signature could be achievable. In case of no patient s signature as with an operation, sedation, and neonate or infancy, specific attention is required to ensure a safe transfusion practice. (Korean J Blood Transfus 2015;26: 266-272) Key words: Transfusion, Patient involvement, Bedside checking, Operation Received on July 24, 2015. Revised on November 27, 2015. Accepted on November 29, 2015 Correspondence to: Kyeong-Hee Kim Department of Laboratory Medicine, Dong-A University College of Medicine, 26 Daeshingongwon-ro, Seo-gu, Busan 49201, Korea Tel: 82-51-240-2850, Fax: 82-51-255-9366, E-mail: progreen@dau.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright C 2015 The Korean Society of Blood Transfusion - 266 -
김보람외 : 수혈전혈액확인에환자참여 서론 수혈은환자혈액의정확한채혈, 정확한검사, 적합한혈액의선택, 올바른환자확인을통한혈액의주입등여러단계에걸쳐이루어지는복잡한행위이다. 그래서실수가동반될수있는위험성을내포하고있으며, 실제로미국뉴욕주에서 10년기간을조사한연구에서 ABO 부적합적혈구가 1/38,000의빈도로실수에의해수혈되었다고보고하였다. 1) 수혈과정의실수를줄이고안전한수혈을위한질적인평가연구 (Qualitative Evaluation for Safer Transfusion (QUEST)) 에서수혈전확인과정이가장중요하다고보고하였다. 2) 수혈의마지막단계인환자확인단계에서실수가발생하면다른환자의혈액이주입되어사고로이어질가능성이아주높다. 혈액을주입하기전에다시한번환자의손목밴드를확인하라는경고라벨을혈액백에부착했던연구 (Prevention of bedside errors in transfusion medicine (PROBE-TM) study) 는실패하였다. 3) 이러한결과는안전한수혈을정착시키기위해서는여러단계의접근이필요하다는것을의미하며, 실제로각의료기관마다수혈의과정이다르고한기관내에서도병동마다차이가있다. 수혈전확인과정을개선시키기위해서는다양한노력을기울여야하며, 수혈과정에참여하는의료진의훈련, 수혈과정의감사 (audit), 자동화된바코드 (bar codes) 를이용한수혈관리시스템의도입등이고려될수있다. 4) 수혈과정에환자들의참여는비교적제한적이었다. 그러나영국을비롯한외국에서는최근수혈의여러과정에환자들의적극적인참여에대한연구가이루어지고있다. 5,6) 국내에서는채혈시환자본인이알고있는혈액형을확인하여 A형, B형, O형, AB형, 모름과같이 5가지항목으 로기록하여환자확인과정에간접적으로환자가참여하게하는연구가있었지만 7) 수혈과정에서환자들의참여에대한연구가보고된바는없다. 바코드시스템과같은수혈관리시스템의도입이쉽지않은국내현실에서환자확인실수로인한수혈사고를줄이고자환자들의참여를검토하게되었다. 동아대학교병원에서는 2010년부터수혈혈액의마지막확인단계에서혈액라벨에환자의서명란을추가하여환자의참여를실시하고있다. 수혈과정의감사를통해서환자서명의빈도를확인하여수혈전확인과정에서환자참여의실제적경험을조사해보고자하였다. 대상및방법 1. 수혈전혈액의환자서명실시 2010년동아대학교병원수혈위원회에서는환자확인실수로인한수혈사고를줄이고자수혈을실시하기전의사, 간호사및환자 3인이함께혈액을확인한후에서명을하기로정책을세웠다. 2개월의시범실시후에각병동에서문제점에대한의견을자유롭게기술할수있는개방형건의사항을제출하도록하였다. 이들건의사항을검토하여개선점을도출하였다. 개선된절차에따라서수혈전혈액확인과정에환자가참여하도록하였다. 2. 환자서명의빈도조사 2013년 1월 1일부터 1월 31일까지동아대학교병원에서수혈받은모든환자를대상으로하였다. 한환자가여러단위의혈액을수혈받기때문에수혈되었던첫번째혈액을대상으로의무기록을조사하였다. 수혈받은혈액의종류, 환자의서명유무를수혈기록지를통하여조사하였 - 267 -
Korean J Blood Transfus Vol. 26, No. 3, 266-272, Dec. 2015 다. 의사, 간호사, 환자의서명유무와서명이빠진경우의원인을분석하였다. 서명이빠진경우의원인은수술, 진정중이거나의식저하, 신생아나유아, Vancomycin Resistant Enterococci (VRE) 감염, 시술중으로나누어서기록하였다. 결과 1. 실제환자참여과정의문제점병동및수술장등의건의사항은다음과같이 5가지로요약할수있었다. 1) 수술중인경우담당의사의서명을받기가힘들다. 2) 혈액백에붙이는서명란라벨이젖어서잘찢어진다. 3) 의사선생님이늦어수혈이늦어지는경우가많다. 4) 환자가비협조적인경우, VRE 감염인경우, 의식이불명료한경우에는환자서명을받기가힘들다. 5) 혈소판및혈장수혈인경우에는혈액단위가많아서업무가가중된다. 2. 실제환자참여과정의개선사항건의사항들을통합하여절차를수립하였다. 안전수혈을위한혈액확인의기본요건은의사와간호사는반드시 2인이함께확인한후에서명하 도록하였다. 환자의의식이명료하고, 협조적인경우에는환자의서명을기재하고, 환자가비협조적인경우나 VRE 감염이있는경우, 의식이불명료한경우에는환자서명란에간호사가대신해서사유를기재하도록하였다. 수술장에서는마취과의사와수술장의간호사 2인이서명하기로하였다. 혈소판및신선동결혈장의경우첫번째단위수혈시작전에의사, 간호사, 환자가함께확인한후에일괄서명이가능하도록하였고, 농축적혈구및전혈의경우에는각혈액단위연결시에도 3인이확인하고서명을하도록하였다. 마지막으로혈액백에붙이는서명란라벨은잘찢어지지않는재질로교체하였다. 3. 환자서명의빈도조사기간중총 4697단위의혈액이출고되었으며, 조사되었던환자수는 576명이었다. 첫번째로수혈이이루어진혈액제제는농축적혈구가 426명 (74.0%), 농축혈소판이 56명 (9.7%), 신선동결혈장이 34명 (5.9%), 백혈구제거농축적혈구가 34명 (5.9%) 등의순이었다. 환자의서명이이루어진경우는 366명 (63.5%) 이었고, 서명하지못한경우는 210명 (36.5%) 이었다 (Table 1). 서명하지못한원인으로는수술중 104명 (49.5%) 이가장많았고, 의식저하혹은진정중 75명 (35.7%), 신생아 Table 1. The distribution of blood components and number of patients involved in the pre-transfusion checking process using patient s signature* Blood components RBC PC LRRBC FFP AP WRBC AB Total N (%) Transfusion with patient s sign 271 39 29 16 7 4 0 366 (63.5) Transfusion without patient s sign 155 17 5 18 2 1 12 210 (36.5) Total patient N (%) 426 (74.0) 56 (9.7) 34 (5.9) 34 (5.9) 9 (1.6) 5 (0.9) 12 (2.1) 576 (100.0) *The blood components denote the first transfusion in patients who had transfusion during January 2013. Abbreviations: RBC, packed red blood cell; PC, platelet concentrates; LRRBC, leukoreduced red blood cell; FFP, fresh frozen plasma; AP, apheresis platelet; WRBC, washed red blood cell; AB, autologous blood. - 268 -
김보람외 : 수혈전혈액확인에환자참여 나유아 7명 (3.3%) 등의순이었다 (Table 2). 의무기록조사에서환자의거부에의한원인으로서명이빠진경우는없었다. 고찰수혈은헌혈자의모집부터침상에서환자에게혈액이주입되고수혈의효과를모니터링하는전과정을포함하는행위라고할수있다. 8) 안전하게검사된혈액제제를수혈이꼭필요한환자에게안전한수혈절차를통해서주입되어야한다. 안전한혈액제제의조제는질병관리본부에서발간한혈액원표준업무안내서를통해서표준화되었으며, 많은발전을이루었다. 9) 혈액의효과적인사용에대해서는수혈요법실시및혈액제제사용에대한수혈가이드라인이질병관리본부주관으로발간및개정되어있다. 10) 그러나안전한수혈을위한절차에대한가이드라인은의료기관평가인증원의기준이나질병관리본부의수혈가이드라인내수혈시의수칙등이산발적으로발표되어있을뿐체계적이고통합적인가이드라인은없는실정이다. 국내에서는안전한수혈을위 한노력으로일개 3차의료기관에서바코드시스템을이용하여약물과수혈에적용한보고가있으며, 11) ABO 혈액형불일치수혈을예방하기위해서 2-2-2 안전수혈캠페인 의제안도있어왔다. 12) 그동안수혈에있어환자들은혈액을주사맞는수동적역할에국한되어왔으나일부외국을중심으로안전한수혈을시행하는데있어환자들의역할에대한체계적인연구가제안되고있다. 5) 환자는수혈의여러과정중에다양한역할로참여할수있는데, 수혈전에임상적으로수혈이꼭필요한지평가하거나수혈동의서작성에참여할수있다. 또한혈액형이나교차적합성검사를위한채혈시손목밴드를확인하는과정에참여할수있다. 혈액제제를수혈받기직전에준비된혈액제제가환자본인의것이맞는지손목밴드나혈액백의표시를보고확인함으로써환자의참여를유도할수있다. 마지막으로수혈중이나수혈을마치고나서수혈의부작용을의료진에게적절히보고하는형식을통해서환자가능동적으로참여할수도있다. 본연구는수혈과정의실수를예방하는데가 Table 2. Causes of transfusion without patient s signature in patients involved in the pre-transfusion checking process* Blood components RBC PC LRRBC FFP AP WRBC AB Total (%) Operation 82 10 0 2 0 0 10 104 (49.5) Unclear consciousness or sedation 55 5 2 12 1 0 0 75 (35.7) Neonate or infancy 6 0 0 1 0 0 0 7 (3.3) VRE infection 2 1 2 0 1 0 0 6 (2.9) During procedures 3 0 1 1 0 0 0 5 (2.4) Blood wastage 1 0 0 2 0 0 2 5 (2.4) No record 6 1 0 0 0 1 0 8 (3.8) Transfusion without patient s sign 155 17 5 18 2 1 12 210 (100.0) *The blood components denote the first transfusion in patients who had transfusion during January 2013. Abbreviations: See Table 1; VRE, Vancomycin Resistant Enterococci. - 269 -
Korean J Blood Transfus Vol. 26, No. 3, 266-272, Dec. 2015 장중요한단계라고알려진혈액과환자를확인하는과정에환자가참여하는것이다. 혈액백라벨에환자의서명을통해서본인의혈액형과본인의이름이인쇄된혈액백을다시확인하는기회를가지는것이다. 서명이이루어진경우는 63.5% 로실제로수술이나의식저하등으로본인이서명을할수없는경우를제외하고대부분의환자가서명에참여하였다. 본연구에서환자가서명을거부한경우는관찰되지않았는데의료진이기술하였던원인을후향적으로연구한것이기때문에실제보다낮게평가되었을가능성이있다. 하지만거부에의한미서명이관찰되지않았다는것은안전한수혈을위한절차라고의료진이설명을하면환자들의참여를이끌어낼수있다는것을알수있다. 수술에의해서명을할수없었던경우가 104 건으로전체미서명건의 49.5% 를차지하였다. 수술이예정되어있는환자의혈액수혈에대한인식설문조사에서 20% 의환자가수혈은항상위험도가있거나, 흔하게위험도가따른다고대답하였고, 의사들의경우는환자들보다더높은 39.1% 가이에응답을하였다. 13) 소아심장수술에서 ABO 불일치혈액을실수로주입했던예의보고도있었다. 14) 이처럼수술중환자는마취로인해의식이없는상황이기때문에수술환자에게발생할수있는여러실수들을신속생리적지지팀 (acute physiological support team) 을구성해고위험수술환자에게적용해서실수의횟수를감소시켰다는보고가있다. 15) 수술다음으로높은미서명의사유는의식이없거나진정상태에있는경우로 35.7% 를차지하였다. 이처럼수술이나진정상태의경우에는 ABO 불일치혈액이주입되더라도불안감, 호흡곤란, 가슴통증등의증상을표시할수없기때문에더욱주의가요구된다고할수있을것이다. 미서명의 3.3% 는신생아나유아의수혈인경우였는데, 영국의 Serious Hazards of Transfusion (SHOT) 보고서에따르면 1996년부터 2005년사이에 264건의소아부적합혈액성분의수혈 (incorrect blood component transfused) 이보고되었다고하였다. 적혈구불출십만건당성인의경우 13회의해로운결과의위험도를보이지만, 18세미만소아청소년의경우 18건, 12개월미만의유아는 37회의빈도를보여소아에서의적혈구수혈에따른위험도가성인보다더높다고분석하였다. 이러한위험도를줄이기위해서는관련가이드라인을잘준수하고, 유소아수혈의특수성을잘이해하고또한의료진간의긴밀한의사소통이필요할것이라고제시하였다. 16) 수혈과정의실수를예방하는데가장중요한단계라고알려진혈액과환자를확인하는과정에환자가참여하는것은환자들의협조로잘이루어질수있었다. 수술이나진정, 소아의경우와같이서명이이루어지기어려운특수한환경은특히 ABO 불일치혈액의주입이일어나기쉬운상황임을인지하고의료인 2명의더욱철저한환자확인이요구됨을알수있었다. 요약 배경 : 수혈은정확한채혈, 정확한검사, 올바른환자확인을통한혈액의주입등여러단계에걸쳐이루어지는복잡한행위이다. 수혈전환자확인단계에서실수가발생하면심각한사고로이어질가능성이높다. 안전한수혈과정에서환자의역할에대해서조사해보고자하였다. 방법 : 동아대학교병원에서는 2010년부터수혈혈액의마지막확인단계에서혈액라벨에환자의서명란을추가하여환자가참여하도록하고있다. 2013년 1월동안동아대학교병원에서수혈 - 270 -
김보람외 : 수혈전혈액확인에환자참여 받은환자의첫번째수혈을대상으로의무기록을조사하였다. 의사, 간호사, 환자의서명유무와서명이빠진경우의원인을분석하여보았다. 결과 : 환자가서명하는중에발생하였던문제점을조사하여개선된절차에따라시행하였다. 조사기간중총 4697단위의혈액이출고되었으며, 대상자는 576명이었다. 수혈이이루어진혈액제제는농축적혈구 426명 (74.0%), 농축혈소판 56 명 (9.7%), 신선동결혈장 34명 (5.9%) 의순이었다. 환자의서명이이루어진경우는 366명 (63.5%) 이었다. 환자가서명하지못한 210명 (36.5%) 중에서는수술중 104명이가장많았고 (49.5%), 의식저하혹은진정중 75명 (35.7%), 신생아나유아 7명 (3.3%) 등의순이었다. 결론 : 환자가서명을함으로써수혈혈액의확인단계에환자의참여를유도할수있었다. 환자서명이이루어지지못한수술, 진정, 신생아나유아와같은특수한경우는의료인 2명의더욱철저한환자확인이요구됨을알수있었다. References 1. Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York State: an analysis of 10 years' experience. Transfusion 2000;40:1207-13 2. Heddle NM, Fung M, Hervig T, Szczepiorkowski ZM, Torretta L, Arnold E, et al; BEST Collaborative. Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST). Transfusion 2012;52:1687-95 3. Murphy MF, Casbard AC, Ballard S, Shulman IA, Heddle N, Aubuchon JP, et al; BEST Research Collaborative. Prevention of bedside errors in transfusion medicine (PROBE-TM) study: a cluster-randomized, matched-paired clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check. Transfusion 2007;47:771-80 4. Murphy MF, Fraser E, Miles D, Noel S, Staves J, Cripps B, et al. How do we monitor hospital transfusion practice using an end-to-end electronic transfusion management system? Transfusion 2012;52:2502-12 5. Davis RE, Vincent CA, Murphy MF. Blood transfusion safety: the potential role of the patient. Transfus Med Rev 2011;25:12-23 6. Davis R, Murphy MF, Sud A, Noel S, Moss R, Asgheddi M, et al. Patient involvement in blood transfusion safety: patients' and healthcare professionals' perspective. Transfus Med 2012;22:251-6 7. Jo KM, Chung Y, Shin S, Roh EY, Yoon JH, Han KS. Checking perceived blood group of the patient upon phlebotomy: additional approach for accurate patient identification and ABO testing. Korean J Blood Transfus 2014;25: 10-7 8. Dzik WH. Emily Cooley lecture 2002: transfusion safety in the hospital. Transfusion 2003; 43:1190-9 9. Division of human blood safety surveillance, Korea Centers for Disease Control and Prevention. Standard operation manual for blood collection center. 2nd ed. Cheongju: Korea Centers for Disease Control and Prevention, 2014:12 10. Division of human blood safety surveillance, Korea Centers for Disease Control and Prevention. Transfusion guideline. 2nd ed. Cheongju: Korea Centers for Disease Control and Prevention, 2013:12 11. Cho MS, Song MR, Jang MR. Evaluation of the bar code medication administration and blood transfusion system in a tertiary hospital. J Korean Acad Nurs Adm 2012;18:23-32 - 271 -
Korean J Blood Transfus Vol. 26, No. 3, 266-272, Dec. 2015 12. Cho D, Hyun J, Ryang DW. Prevention of ABO incompatible blood transfusion: '2-2-2 safe blood transfusion campaign'. Korean J Blood Transfus 2013;24:79-81 13. Vetter TR, Adhami LF, Porterfield JR Jr, Marques MB. Perceptions about blood transfusion: a survey of surgical patients and their anesthesiologists and surgeons. Anesth Analg 2014;118:1301-8 14. Aliç Y, Akpek EA, Dönmez A, Ozkan S, Perfusionist GY, Aslamaci S. ABO-incompatible blood transfusion and invasive therapeutic approaches during pediatric cardiopulmonary bypass. Anesth Analg 2008;107:1185-7 15. Clarke DL, Kong VY, Naidoo LC, Furlong H, Aldous C. The introduction of an acute physiological support service for surgical patients is an effective error reduction strategy. Int J Surg 2013;11:989-92 16. Stainsby D, Jones H, Wells AW, Gibson B, Cohen H; SHOT Steering Group. Adverse outcomes of blood transfusion in children: analysis of UK reports to the serious hazards of transfusion scheme 1996-2005. Br J Haematol 2008;141:73-9 - 272 -