Improvement in transfusion safety using a specially designed transfusion wristband

Abstract

Fatal haemolytic transfusion reaction due to ABO incompatibility occurs mainly as a result of clerical error. A blood sample drawn from the wrong patient and labelled as another patient's will not be detected by the blood bank unless there is a previous ABO grouping result. We report here the detection of such clerical error by the use of a specially designed transfusion wristband. The wristband has the following special features: (i) once attached, it cannot be removed except by cutting; (ii) it has a pocket containing a transfusion label; (iii) a unique transfusion barcode is printed on each transfusion label and the corresponding wristband simultaneously by computer technology; (iv) a transfusion label removed from the wristband after attachment to the patient has a characteristic tear-mark distinguishing it from one removed prior to attachment. The blood bank only accepted those specimens bearing the tear-marked transfusion labels. All blood units for this patient were labelled with this unique transfusion code together with the patient's details. The nurses counter-checked the transfusion code on the blood units against the transfusion code on the patient's transfusion wristband prior to transfusion. If the blood sample for compatibility testing was drawn from the 'wrong' patient, the intended patient either did not carry a wristband or the transfusion codes did not match at all. Pretransfusion compatibility tests were performed on 2189 patient samples using this procedure. It was well accepted by both ward and blood bank staff. Two potential mismatched transfusions were avoided. These two clerical errors would not have been detected because neither patient had previous ABO grouping results.

Safety and reliability of Radio Frequency Identification Devices in Magnetic Resonance Imaging and Computed Tomography

“…A number of RFID applications have been implemented in hospitals so far, mostly for logistic purposes such as material tracking or inventory management, according to the original applications of the technology [2,21-23]. Only recently, more complex applications have been implemented in hospitals, for example in patient-care management processes such as blood transfusion or the prevention of wrong side surgery [1,3,13,24-27].…”

Hemolytic Transfusion Reactions

“…One such system uses a plastic lock that is preset to a three-letter code at the time of blood component issuance by the blood bank. 92 An alternative system uses bar codes on patient wristbands, blood sample tubes, blood component bags, and nurses' identifi cation badges; and point-of-care reading devices to verify identity. Use of this system in one hospital over the course of 1 year detected two misidentifi ed pretransfusion blood samples, and prevented one attempt to transfuse blood to the wrong patient.…”

Administration Safety of Blood Products - Lessons Learned from a National Registry for Transfusion and Hemotherapy Practice

“…In addition, other IT-associated measures that more or less are based on the data management systems already in use were recommended, such as the electronic order of blood products [26] and identification checks [27,28].…”