Technology for Enhanced Transfusion Safety

Abstract

Data from reporting systems around the world document that non-infectious hazards are the leading cause of serious morbidity or mortality resulting from blood transfusion. Among these non-infectious hazards, mis-transfusion represents the most frequently observed serious hazard and occurs at an estimated rate of 1 in 14,000 transfusions. Mistransfusion events result from "lapse errors" (slip ups) rather than cognitive mistakes. Case Summary-Ms JohnstonOn a Thursday evening, you are paged to consult on the management of a patient (Mary Johnston) who has received incompatible blood. The patient is a 48-year-old woman who underwent surgery that morning for removal of a 2 cm, right para-renal mass. The surgery was uncomplicated and a frozen-section pathology specimen was read as a benign adenoma. She received 2.8 L of crystalloid solution during surgery. Post-operatively, her hematocrit was found to be 24% and she was given one unit of group A packed RBCs over 2 hours. Towards the end of the transfusion, she developed a shaking chill and her temperature rose from 99°F to 101°F. Her urine was red as a result of the renal surgery. A blood culture and complete blood count (CBC) were sent and the CBC specimen was reported as hemolyzed with a Hct = 24%. A transfusion reaction evaluation was sent to the blood bank accompanied by the empty blood bag and a freshly drawn post-transfusion specimen. The blood bank called back to report that a "wrong blood transfusion" had likely occurred. The name and medical record number attached to the empty blood bag tag (Mary Johnson, MRN 2395783) did not match that on the post-transfusion specimen (Mary Johnston, MRN 2395837). There was no pre-op sample on file for

Acute extravascular hemolytic transfusion reaction due to anti-Kpa antibody missed by electronic crossmatch

“…In an ideal world, transfusion requisitions would contain a wealth of relevant clinical information to enable laboratories to select appropriate patients in whom to perform this extended testing. Computer provider order entry (CPOE) may be a tool that will enable this and it is important for transfusion specialists to advocate for technologies that will allow the safest, yet most fiscally responsible testing algorithms in their hospitals [12]. Until such utopian visions for transfusion testing and therapy are achieved, it is important to report cases such as these that may assist others in timely identification and management of similar transfusion reactions, and enable reflection on the various strategies for antibody identification and crossmatching policies and procedures and their impact on patient care.…”

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

“…Whether or not the technical refinement of vein-to-vein IT systems should be awaited before implementation is a matter of controversial debate. However, a number of problems are still unsolved, e.g., the choice of frequency and interference effects when applying RFID technology [22,[53][54][55]. Lastly, when considering the German hemovigilance report [3], it becomes obvious that administration safety is not well reported in Germany.…”

“…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.…”

“…Its importance and potential benefit has only recently been proven [22,41]. Mismatches in 1% of transfusion processes could be avoided by using a scannerbased system [19], although its implementation is not free of complications [42].…”

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

“…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).…”