Adverse Events Associated with Bone Marrow Biopsy In A Resident Training Program; First Do No Harm

Bone marrow aspirates and biopsies are commonly performed to evaluate a variety of hematological abnormalities. Generally, it is regarded as a safe procedure; however, the complication rate is uncertain. Much of the data surrounding bone marrow complications derives from retrospective, voluntary reported data from the UK and is estimated to occur in 0.08 – 0.12% of procedures. Data also suggests that the quality of bone marrow specimens may vary with operator expertise.

In this report we present a case series of adverse events following bone marrow examinations performed by internal medical residents. In response to these procedural outcomes, we will outline a comprehensive quality improvement and quality assurance initiative designed to improve resident training, ensure patient safety, and enhance sample quality.

Four cases of attempted bone marrow aspirate and biopsy on the Clinical Teaching Units (CTU) at the Health Science Centre from June 2010 to April 2011 were identified. All four procedures were performed by internal medicine residents at varying levels of training and were unsuccessful despite multiple attempts. In two of the cases the GIM attending was also unsuccessful in obtaining sample. Two cases of major bleeding occurred necessitating multiple units of red blood cells to be transfused and one patient required admission to the intensive care unit. In another case the patient was unable to ambulate for 3 days due to severe leg pain at the site of attempted biopsy. Improper landmarking for the procedure was common in all cases and confirmed with 3D computed axial tomographic rendering in 2 patients.

In response to these patient adverse patient outcomes and with patient safety in mind, we decided that, until a more detailed plan could be developed, all bone marrow biopsies performed on the CTU will be supervised by an attending hematologist. With involvement from stakeholders in internal medicine, hematology and hematopathology, we developed a multifaceted quality improvement and assurance initiative. We designed an educational curriculum starting with an academic half day that would consist of an instructional video followed by a practical session in the Clinical Learning and Simulation Facility. This will allow residents to strengthen communication skills by obtaining informed consent and build important procedural skills through the use of simulators. Learning will be reinforced through resident rotations on the Hematology service that will include participation in a weekly bone marrow clinic. This clinic would allow residents an opportunity to perform a number of successive bone marrows in a controlled environment under the supervision of an attending hematologist. To evaluate resident performance and adverse events, a data collection instrument will be developed to monitor the success of these interventions for bone marrows completed on the CTUs. A credentialing process to ensure competency of resident training is being considered.

With the implementation of a multifaceted and comprehensive strategy we expect to improve resident training, ensure patient safety, and enhance sample quality resulting in less need for repeat procedures.

No relevant conflicts of interest to declare.