Improvement in transfusion safety using a new blood unit and patient identification system as part of safe transfusion practice

Abstract

A new patient and blood unit identification system designed to confirm the identity of crossmatched blood products and that of the intended recipient was evaluated. Six hundred seventy-two red cell concentrates were transfused to 312 patients. Participating hospital personnel and patients were interviewed regarding the use and benefit of this unique system, which incorporates a "lock-box" approach to the identification process. The product and procedure were accepted unanimously and enthusiastically, and three potential mistransfusions were avoided by use of the system during the limited period of observation. This type of approach to the identification process affords greater security than conventional practices and minimally burdens staff.

Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention

“…Such systems, however, are often not used or are used incorrectly. Evolving technologies (such as barrier systems and bar codes) improve safety and efficiency, 33,34 while the presence of national patient identification systems in Sweden and Finland has been associated with rates of miscollected samples too low to estimate. 35 Reported fatalities due to HTRs secondary to non-ABO antibodies have, however, increased in the United States.…”

Wrong-Side/Wrong-Site, Wrong-Procedure, and Wrong-Patient Adverse Events

“…31,[65][66][67] Learning about transfusion errors through mandatory no-fault reporting, including the classification, analysis, and monitoring of mistransfusions and near misses, has helped foster a more resilient and reliable safety culture in transfusion medicine. 68,69 Reporting systems seem to enhance safety culture through more transparency, communication, and accountability.…”

Bedside Transfusion Errors

“…They may, however, reflect a situation prevailing in many centers throughout the world lacking the technology for bedside computerized matching of a recipient's identity against that of a blood unit [9]. The use of a 'lack-box' system might have prevented some errors found in this survey and could be useful in hospitals lacking the capa bilities to develop electronic controls [11], The practical ities of transfusing were delegated to a great number of individuals with heterogeneous training and motivations such as physicians, specialized nurses, perfusionists, regu lar ward nursing personnel. Our work underscores the pitfalls of such a decentralized system.…”