Improving transfusion safety: implementation of a comprehensive computerized bar code–based tracking system for detecting and preventing errors

Askeland, Ryan W.; McGrane, S.; Levitt, J.S.; Dane, Susan K; Greene, Deborah L.; Vandeberg, Jeff; Walker, Kristy; Porcella, Aleta; Herwaldt, Loreen A.; Carmen, Lee; Kemp, John D.

doi:10.1111/j.1537-2995.2008.01668.x

Cited by 43 publications

(46 citation statements)

References 23 publications

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“…However, a large observational audit revealed a failure to perform the final bedside check [9], in which the practice compliance of healthcare workers for identification and vital sign monitoring of patients receiving blood transfusions were substandard in many hospitals. A bar code-based EIS is ideally suited to pre-transfusion checking requirements and has recently been reported to significantly improve transfusion practice [10][11][12][13][14][15][16][17][18]. The SHOT scheme also reported that approximately 30% of errors pertaining to IBCT events occur in the hospital transfusion laboratory [7].…”

Section: Discussionmentioning

confidence: 99%

Electronic Pre-Transfusion Check at the Bedside: Experience in a University Hospital

Ohsaka¹

2017

HTIJ

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Although the current risks of viral transmission through blood components are very small, mistransfusion in which the wrong blood is transfused to the wrong patient remains the most common type of error in transfusion practice. Many studies have revealed that transfusion errors occur frequently in clinical areas, with the most common error being failure to perform the final patient identification check at the bedside. Thus, pre-transfusion check at the bedside is the most critical step for the prevention of mistransfusion. Machine-readable identification technology, especially an electronic identification system (EIS), is ideally suited to pre-transfusion check requirements. An experience at the Juntendo University Hospital (JUH) showed that the bar code-based EIS works well on a hospital-wide basis in the setting of regular allogeneic blood transfusion, preoperative autologous blood donation (PAD) and transfusion, pediatric transfusion and hematopoietic progenitor cell (HPC) infusion at the bedside. Approximately 110,000 blood components have been transfused over a 10.5-year period without a single mistransfusion. The overall compliance rate with electronic pre-transfusion check at the bedside was 98.2%. Human error was the most frequent cause of errors leading to failure of the 'second' electronic pre-transfusion check. If we want to reduce the risk of mistransfusion to improve transfusion safety, we have to address the issue at the hospital level, with a system-based approach.

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Section: Discussionmentioning

confidence: 99%

Electronic Pre-Transfusion Check at the Bedside: Experience in a University Hospital

Ohsaka¹

2017

HTIJ

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“…The details of the development process, creation of the software and modifications have been described previously (Askeland et al 2008). Key elements and modifications are summarized.…”

Section: Methodsmentioning

confidence: 99%

“…A wide variety of new technologies have subsequently flourished, with most using bar-code and radiofrequency labels (Askeland et al 2008;Dzik 2005Dzik , 2006Dzik et al 2003;Miyata et al 2004;Murphy and Kay 2004a;Turner et al 2003). The University of Iowa Hospitals and Clinics (UIHC) developed and implemented a comprehensive computerized bar-code-based patient and blood product identification system in February 2005 (Askeland et al 2008).…”

mentioning

confidence: 99%

Enhancing Transfusion Safety with an Innovative Bar-Code-Based Tracking System

Askeland¹,

McGrane²,

Reifert³

et al. 2009

hcq

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“…Special IT-based safety features are proposed to erase user errors, e.g., the use of bar codes [19] and radiofrequency identification (RFID) tracking systems [20][21][22] from blood sampling to transfusion [23]. Using a computerized administration guide, the documentation of drug and blood administration can be improved.…”

Section: Discussionmentioning

confidence: 99%

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

Frietsch

Thomas

Schöler

et al. 2017

Transfus Med Hemother

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Background: Compared to blood component safety, the administration of blood may not be as safe as intended. The German Interdisciplinary Task Force for Clinical Hemotherapy (IAKH) specialized registry for administration errors of blood products was chosen for a detailed analysis of reports. Methods: Voluntarily submitted critical incident reports (n = 138) from 2009 to 2013 were analyzed. Results: Incidents occurred in the operation room (34.1%), in the ICU (25.2%), and in the peripheral ward (18.5%). Procedural steps with errors were administration to the patient (27.2%), indication and blood order (17.1%), patient identification (17.1%), and blood sample withdrawal and tube labeling (18.0%). Bedside testing (BST) of blood groups avoided errors in only 2.6%. Associated factors were routine work conditions (66%), communication error (36%), emergency case (26%), night or weekend team (39%), untrained personnel (19%). Recommendations addressed process and quality (n = 479) as well as structure quality (n = 314). In 189 instances, an IT solution would have helped to avoid the error. Conclusions: The administration process is prone to errors at the patient assessment for the need to transfuse and the application of blood products to patients. BST is only detecting a minority of handling errors. According to the expert recommendations for practice improvement, the potential to improve transfusion safety by a technical solution is considerable.

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Improving transfusion safety: implementation of a comprehensive computerized bar code–based tracking system for detecting and preventing errors

Abstract: The bar code-based computerized tracking system detected and prevented identification and matching errors, thereby reducing the proportion of blood samples rejected and increasing patient safety.

Cited by 43 publications

References 23 publications

Electronic Pre-Transfusion Check at the Bedside: Experience in a University Hospital

Electronic Pre-Transfusion Check at the Bedside: Experience in a University Hospital

Enhancing Transfusion Safety with an Innovative Bar-Code-Based Tracking System

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

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