In response to an emergent blood transfusion scenario, emergency department (ED) staff followed policy and contacted the blood bank to start the unmatched blood acquisition process in case rapid transfusion was needed. However, once the order was received, the blood bank encountered several barriers to complete the request.

Just as reporting adverse events helps improve patient safety, reporting workplace incidents that have harmed or had the potential to harm employees can inspire change to protect healthcare staff as well as patients and visitors.

At one facility, over a few months several incidents occurred involving patients in diabetic ketoacidosis (DKA), a life-threatening complication in which too much acid (ketones) builds up in the blood, in both the emergency department and acute care.