Prevention of bedside errors in transfusion medicine (PROBE‐TM) study: a cluster‐randomized, matched‐paired clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check

Murphy, Michael; Casbard, Angela; Ballard, S.; Shulman, Ira A.; Heddle, Nancy M.; AuBuchon, James P.; Wendel, Silvano; Thomson, Amanda; Hervig, Tor; Downes, Katharine A.; Carey, Patricia M.; Dzik, Walter H.

doi:10.1111/j.1537-2995.2007.01189.x

Cited by 42 publications

(36 citation statements)

References 15 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…A review of the literature identifies articles published about medication errors, wrong surgical site errors, and transfusion errors. [1][2][3][4][5] A root cause of many of these errors is lack of proper patient ID. [1][2][3][4][5] The Joint Commission reported that 13% of surgical errors and 67% of transfusion errors were due to patient ID errors.…”

mentioning

confidence: 99%

“…[1][2][3][4][5] A root cause of many of these errors is lack of proper patient ID. [1][2][3][4][5] The Joint Commission reported that 13% of surgical errors and 67% of transfusion errors were due to patient ID errors. 6,7 Between January 2000 and March 2003, the Veterans Affairs National Center for Patient Safety reported that more than 100 root cause analyses involved patient ID errors.…”

mentioning

confidence: 99%

See 1 more Smart Citation

Reduction in Pediatric Identification Band Errors: A Quality Collaborative

et al. 2012

View full text Add to dashboard Cite

show abstract

mentioning

confidence: 99%

mentioning

confidence: 99%

Reduction in Pediatric Identification Band Errors: A Quality Collaborative

et al. 2012

View full text Add to dashboard Cite

show abstract

“…An increase in transfusion safety may require the introduction of further systems [14], e.g. a tag on blood bags reminding staff to check a patient's wristband [25].…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Four Bedside Test Systems for Card Performance, Handling and Safety

Giebel¹,

Picker²,

Gathof³

2007

Transfus Med Hemother

View full text Add to dashboard Cite

Objective: Pretransfusion ABO compatibility testing is a simple and required precaution against ABO-incompatible transfusion, which is one of the greatest threats in transfusion medicine. While distinct agglutination is most important for correct test interpretation, protection against infectious diseases and ease of handling are crucial for accurate test performance. Therefore, the aim of this study was to evaluate differences in test card design, handling, and user safety. Design: Four different bedside test cards with pre-applied antibodies were evaluated by 100 medical students using packed red blood cells of different ABO blood groups. Criteria of evaluation were: agglutination, labelling, handling, and safety regarding possible user injuries. Criteria were rated subjectively according to German school notes ranging from 1 = very good to 6 = very bad/insufficient. Results: Overall, all cards received very good/good marks. The ABO blood group was identified correctly in all cases. Three cards (no. 1, no. 3, no. 4) received statistically significant (p < 0.008) prominence (mean values shown) concerning clearness of agglutination (1.7-1.9 vs. 2.4 for no. 2). Systems with dried antibodies (no. 2, no. 4) outmatched the other systems with respect to overall test system performance (2.0 vs. 2.8-2.9), labelling (1.5 vs. 2.2-2.4), handling (1.9-2.0 vs. 2.5), and user safety (2.5 vs. 3.4). Analysis of card self-explanation revealed no remarkable differences. Conclusion: Despite good performance of all card systems tested, the best results when including all criteria evaluated were obtained with card no. 4 (particularly concerning clear agglutination), followed by cards no. 2, no. 1, and no. 3.

show abstract

“…Of course, not all quality initiatives succeed, 15 and ''maintaining the gain'' of quality improvements is a challenge requiring constant vigilance. Our own experience has convinced us that a focused transfusion quality-improvement program is well worth the considerable effort we continue to invest.…”

Section: -14mentioning

confidence: 99%

Managing Transfusion Service Quality

Blaylock

Lehman²

2011

Archives of Pathology &Amp; Laboratory Medicine

View full text Add to dashboard Cite

N Context.-Providing blood products for transfusions is a complex process subject to errors both within and outside the transfusion service. Transfusion-related errors can have grave consequences for the patient undergoing transfusion. As with many processes performed within health care systems, there is an expectation of error-free practice. Although this is an unobtainable goal, a focused qualitymanagement plan, employing a medical event reporting system in a just working environment, can effect measurable system-quality improvement.Objective.-To illustrate the intrinsic value of qualityimprovement activities through discussion of examples of quality misadventures from our transfusion service during the past 20 years. Data Sources.-Examples of quality-improvement activities were extracted from our quality-system archives. The published literature on transfusion quality was reviewed.Conclusions.-Active reporting, structured investigation, and systematic resolution of transfusion-related errors are effective methods for improving and maintaining transfusion quality.

show abstract

Prevention of bedside errors in transfusion medicine (PROBE‐TM) study: a cluster‐randomized, matched‐paired clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check

Cited by 42 publications

References 15 publications

Reduction in Pediatric Identification Band Errors: A Quality Collaborative

Reduction in Pediatric Identification Band Errors: A Quality Collaborative

Evaluation of Four Bedside Test Systems for Card Performance, Handling and Safety

Managing Transfusion Service Quality

Contact Info

Product

Resources

About