Human error-a significant cause of transfusion mortality

Analysis of the effect and influencing factors of a clinical competency-oriented prospective pre-job training programme on the comprehensive ability of new employees in the department of transfusion medicine

BACKGROUND

The subject of pre-job training for transfusion service laboratory technicians is very important. The key is how to make a reasonable systematic training programme to improve the effectiveness of training.

METHODS

A prospective training programme was conducted and an assessment was performed at enrollment (baseline) and reassessment after 3-months training, using the same tools with a validated questionnaire.

RESULTS

Clinical competency-oriented prospective pre-job training significantly improves the clinical transfusion-related comprehensive skills of new employees. The post-training assessment score was significantly affected by undergraduate major.

CONCLUSION

This study provided a clinical competency-oriented training programme for new employees in the department of transfusion medicine that could effectively enhance their comprehensive abilities.

Electronic witnessing in the medically assisted reproduction laboratory: insights and considerations after 10 years of use

STUDY QUESTION

What have we learnt after 10 years of electronic witnessing?

SUMMARY ANSWER

When applied correctly, an electronic witnessing system can replace manual witnessing in the medically assisted reproduction lab to prevent sample mix-up.

WHAT IS KNOWN ALREADY

Electronic witnessing systems have been implemented to improve the correct identification, processing, and traceability of biological materials. When non-matching samples are simultaneously present in a single workstation, a mismatch event is generated to prevent sample mix-up.

STUDY DESIGN, SIZE, DURATION

This evaluation investigates the mismatch and administrator assign rate over a 10-year period (March 2011-December 2021) with the use of an electronic witnessing system. Radiofrequency identification tags and barcodes were used for patient and sample identification. Since 2011, IVF and ICSI cycles and frozen embryo transfer cycles (FET) were included; IUIs cycles were included since 2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The total number of tags and witnessing points were recorded. Witnessing points in a particular electronic witnessing system represent all the actions that have been performed from gamete collection through embryo production, to cryopreservation and transfer. Mismatches and administrator assigns were collected and stratified per procedure (sperm preparation, oocyte retrieval, IVF/ICSI, cleavage stage embryo or blastocyst embryo biopsy, vitrification and warming, embryo transfer, medium changeover, and IUI). Critical mismatches (such as mislabelling or non-matching samples within one work area) and critical administrator assigns (such as samples not identified by the electronic witnessing system and unconfirmed witnessing points) were selected.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 109 655 cycles were included: 53 023 IVF/ICSI, 36 347 FET, and 20 285 IUI cycles. The 724 096 used tags, led to a total of 849 650 witnessing points. The overall mismatch rate was 0.251% (2132/849 650) per witnessing point and 1.944% per cycle. In total, 144 critical mismatches occurred over the different procedures. The yearly mean critical mismatch rate was 0.017 ± 0.007% per witnessing point and 0.129 ± 0.052% per cycle. The overall administrator assign rate was 0.111% (940/849 650) per witnessing point and 0.857% per cycle, including 320 critical administrator assigns. The yearly mean critical administrator assign rate was 0.039 ± 0.010% per witnessing point and 0.301 ± 0.069% per cycle. Overall mismatch and administrator assign rates remained fairly stable during the evaluated time period. Sperm preparation and IVF/ICSI were the procedures most prone to critical mismatch and administrator assigns.

LIMITATIONS, REASONS FOR CAUTION

The procedures and methods of integration of an electronic witnessing system may vary from one laboratory to another and result in differences in the potential risks related to sample identification. Individual embryos cannot (yet) be identified by such a system; this makes extra manual witnessing indispensable at certain critical steps where potential errors are not recorded. The electronic witnessing system still needs to be used in combination with manual labelling of both the bottom and lid of dishes and tubes to guarantee correct assignment in case of malfunction or incorrect use of radiofrequency identification tags.

WIDER IMPLICATIONS OF THE FINDINGS

Electronic witnessing is considered to be the ultimate tool to safeguard correct identification of gametes and embryos. But this is only possible when used correctly, and proper training and attention of the staff is required. It may also induce new risks, i.e. blind witnessing of samples by the operator.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was either sought or obtained for this study. J.S. presents webinars on RIW for CooperSurgical. The remaining authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

Sample collection for pre-transfusion crossmatching: Benefits of using an electronic identification system

BACKGROUND

Transfusion of ABO blood group-mismatched blood or administration to the wrong recipient may result in fatal adverse events. To prevent these types of errors, various strategies have been employed. Recently, we developed a novel sample collection workflow for the pre-transfusion crossmatching test and patient recognition. This study aimed to analyse the usage of the new workflow and improvements in outcomes.

METHODS

We analysed the number of crossmatching and wrong-patient errors among the blood transfusion cases during 3 years of data collection (from August 2018 to July 2021). From May 2021 to July 2021, the new workflow was implemented. Outcomes were calculated according to the department type, patient age and processing time. The sample processing time was defined as the time from placing the order to lab arrival.

RESULTS

The new workflow utilisation increased from 50.7% to 80.3% and wrong-patient errors decreased annually. The new workflow was used for more adults (3001/3680 samples, 81.5%) than paediatric cases (345/522 samples, 65.5%; p < 0.001) and in general wards than in the emergency room or intensive care unit. The sample processing time differed according to ward type and timing of the request (day: 28.80, 2.43-3889.43 min, night: 3.36, 2.72-1671.47 min; p < 0.001).

CONCLUSION

Wrong-patient errors were reduced without increasing sample-processing time after introducing the new workflow which included using an electronic identification system. The time needed for the blood processing differed according to the ward type, patient age, and timing of the request. Patient safety can be promoted by managing these factors and using an electronic identification system.

Transfusion medicine and blood banking education and training for blood establishment laboratory staff: A review of selected countries in Africa

BACKGROUND

Avoidable human error is a significant cause of transfusion adverse events. Adequately trained, laboratory staff in blood establishments and blood banks, collectively blood facilities, are key in ensuring high-quality transfusion medicine (TM) services. Gaps in TM education and training of laboratory staff exist in most African countries. We assessed the status of the training and education of laboratory staff working in blood facilities in Africa.

STUDY DESIGN AND METHODS

A cross-sectional study using a self-administered pilot-tested questionnaire was performed. The questionnaire comprised 26 questions targeting six themes. Blood facilities from 16 countries were invited to participate. Individually completed questionnaires were grouped by country and descriptive analysis performed.

RESULTS

Ten blood establishments and two blood banks from eight African countries confirmed the availability of a host of training programs for laboratory staff; the majority of which were syllabus or curriculum-guided and focused on both theoretical and practical laboratory skills development. Training was usually preplanned, dependent on student and trainer availability and delivered through lecture-based classroom training as well as formal and informal on the job training. There were minimal online didactic and self-directed learning. Teaching of humanistic values appeared to be lacking.

CONCLUSION

We confirmed the availability of diverse training programs across a variety of African countries. Incorporation of virtual learning platforms, rather than complete reliance on didactic, in-person training programs may improve the education reach of the existing programs. Digitalization driven by the coronavirus disease 2019 pandemic may provide an opportunity to narrow the knowledge gap in low- and middle-income countries (LMICs).

A survey of blood transfusion errors in Aichi Prefecture in Japan: Identifying major lapses threatening the safety of transfusion recipients

BACKGROUND

Despite recent progress in blood systems, transfusion errors can occur at any time from the moment of collection through to the transfusion of blood and blood products. This study investigated the actual statuses of blood transfusion errors at institutions of all sizes in Aichi prefecture.

MATERIALS AND METHODS

We investigated 104 institutions that perform 98 % of the blood transfusions in Aichi prefecture, and investigated the errors (incidents/accidents) that occurred at these facilities over 6 months (April to September, 2017). Incident/accident data were collected from responses to questionnaires sent to each institution; these were classified according to the categories and risk levels.

RESULTS

Ninety-seven of the 104 institutions (93.3 %) responded to the questionnaire; a total of 688 incidents/accidents were reported. Most (682 cases; 99.2 %), were classified as risk level 2; however, 6 were level 3 and over, which included problems with autologous transfusion and inventory control. Approximately one-half of the incidents/accidents (394 cases; 57.3 %), were related to verification and the actual administration of blood products at the bedside; more than half of these incidents/accidents occurred at large-volume institutions. Meanwhile, a high frequency of incidents/accidents related to transfusion examination and labeling of blood products was observed at small- or medium-sized institutions. The reasons for most of these errors were simple mistakes and carelessness by the medical staff.

CONCLUSIONS

Our results emphasize the importance of education, operational training, and compliance instruction for all members of the medical staff despite advances in electronic devices meant to streamline transfusion procedures.

After Hour Blood Transfusions: A Transfusion Service Perspective

Optimal functioning of blood transfusion service during after hours with limited resources are highly challenging. Best transfusion practice guidelines recommends to avoid non-urgent transfusions during out-of-core hours for the concern of patient's safety. This study aimed to evaluate the after hour packed red cell transfusion practice and to identify the proportion of avoidable transfusions in our center. The transfusion requests received, cross-matched and issued between 8 p.m. and 8 a.m. from September 2015 to August 2016 were analysed and categorized into 3E's based on the clinical need as Group I-evident need, Group 2-empirical need and Group 3-elective need. The proportion of avoidable transfusion in each group was noted based on BCSH guidelines on red cell transfusion including the patient's clinical, laboratory parameters and transfusion details. The proportion of PRBC requests received, crossmatched and issued between 8 p.m. and 8 a.m. were 24.45%, 23.84% and 27.15% respectively. The rationale for PRBC transfusion documented for evident, empirical and elective need were 56.95%, 29.34% and 13.71% respectively. Out of which, 19.21% [876/4559] was identified as avoidable transfusions providing no immediate clinical benefit to patients. This study highlights the proportion of avoidable transfusion during after hours in our center and emphasizes the need for transfusion guidelines that recommends to restrict after hour transfusions to those patients with active bleeding or urgent clinical need in order to prevent transfusion related adverse events and improve patient safety.

A Sustainable Decision-Making Framework for Transitioning to Robotic Welding for Small and Medium Manufacturers

Small and medium-sized enterprises (SMEs) face challenges in implementing industrial robotics in their manufacturing due to limited resources and expertise. There is still good economic potential in using industrial robotics, however, due to manufacturers leaning toward newer technology and automated processes. The research on sustainability decision-making for transitioning a traditional process to a robotic process is limited for SMEs. This study presents a systemic framework for assessing the sustainability of implementing robotic techniques in key processes that would benefit SMEs. The framework identifies several key economic, technical, and managerial decision-making factors during the transition phase. Sustainability assessments, including cost, environmental impact, and social impact, are used in the framework for engineers and managers to evaluate the technical and sustainability trade-offs of the transition. A case study was conducted on a typical US metal fabrication SME focusing on transitioning a shielded metal arc welding (SMAW) process to a robotic gas metal arc welding (GMAW) process. A sustainability assessment was conducted following the framework. The results suggest that the transition phase involves numerous factors for engineers and managers to consider and the proposed framework will benefit SMEs by providing an analytical method for industrial robotics implementation decision-making.

Transfusion Medicine and Molecular Genetic Methods

Transfusion procedures are always complicated by potential genetic mismatching between donor and recipient. Compatibility is determined by several major antigens, such as the ABO and Rhesus blood groups. Matching for other blood groups (Kell, Kidd, Duffy, and MNS), human platelet antigens, and human leukocyte antigens (HLAs) also contributes toward the successful transfusion outcomes, especially in multitransfused or highly immunized patients. All these antigens of tissue identity are highly polymorphic and thus present great challenges for finding suitable donors for transfusion patients. The ABO blood group and HLA markers are also the determinants of transplant compatibility, and mismatched antigens will cause graft rejection or graft-versus-host disease. Thus, a single and comprehensive registry covering all of the significant transfusion and transplantation antigens is expected to become an important tool in providing an efficient service capable of delivering safe blood and quickly locating matching organs/stem cells. This review article is intended as an accessible guide for physicians who care for transfusion-dependent patients. In particular, it serves to introduce the new molecular screening methods together with the biology of these systems, which underlies the tests.

Red Blood Cell Agglutination for Blood Typing Within Passive Microfluidic Biochips

Pre-transfusion bedside compatibility test is mandatory to check that the donor and the recipient present compatible groups before any transfusion is performed. Although blood typing devices are present on the market, they still suffer from various drawbacks, like results that are based on naked-eye observation or difficulties in blood handling and process automation. In this study, we addressed the development of a red blood cells (RBC) agglutination assay for point-of-care blood typing. An injection molded microfluidic chip that is designed to enhance capillary flow contained anti-A or anti-B dried reagents inside its microchannel. The only blood handling step in the assay protocol consisted in the deposit of a blood drop at the tip of the biochip, and imaging was then achieved. The embedded reagents were able to trigger RBC agglutination in situ, allowing for us to monitor in real time the whole process. An image processing algorithm was developed on diluted bloods to compute real-time agglutination indicator and was further validated on undiluted blood. Through this proof of concept, we achieved efficient, automated, real time, and quantitative measurement of agglutination inside a passive biochip for blood typing which could be further generalized to blood biomarker detection and quantification.

Serious Adverse Transfusion Reactions Reported in the National Recipient-Triggered Trace Back System in Korea (2006-2014)

BACKGROUND

Adverse transfusion reactions (ATRs) are clinically relevant to patients with significant morbidity and mortality. This study aimed to review the cases of ATR reported in the recipient-triggered trace back system for a recent nine-year period in Korea.

METHODS

Nine-year data obtained from 2006 to 2014 by the trace back system at the Division of Human Blood Safety Surveillance of the Korean Centers for Disease Control (KCDC) were reviewed. The suspected cases were assessed according to six categories: (i) related to, (ii) probably related to, (iii) probably not related to, (iv) not related to transfusion, (v) unable to investigate, and (vi) under investigation.

RESULTS

Since 2006, 199 suspected serious ATRs were reported in hospitals and medical institutions in Korea, and these ATRs were reassessed by the division of Human Blood Safety Surveillance of the KCDC. Among the reported 193 cases as transfusion related infections, hepatitis C virus (HCV) infection (135, 67.8%) was reported most frequently, followed by hepatitis B virus (HBV) infection (27, 13.6%), HIV infection (13, 6.5%), syphilis (9, 4.5%), malarial infection (4, 2.0%), other bacterial infections (3, 1.5%), HTLV infection (1, 0.5%), and scrub typhus infection (1, 0.5%), respectively. Of the 199 cases, 13 (6.5%) cases were confirmed as transfusion-related (3 HCV infections, 3 malarial infections, 1 HBV infection, 2 Staphylococcus aureus sepsis, 3 transfusion-related acute lung injuries, and 1 hemolytic transfusion reaction).

CONCLUSIONS

This is the first nationwide data regarding serious ATRs in Korea and could contribute to the implementation of an effective hemovigilance system.

Delta check for blood groups: A step ahead in blood safety

BACKGROUND:

Blood grouping is the single most important test performed by each and every transfusion service. A blood group error has a potential for causing severe life-threatening complications. A number of process strategies have been adopted at various institutions to prevent the occurrence of errors at the time of phlebotomy, pretransfusion testing, and blood administration. A delta check is one such quality control tool that involves the comparison of laboratory test results with results obtained on previous samples from the same patient.

MATERIALS AND METHODS:

We retrieved the records of all transfusion-related incidents reported in our institute, between January 2008 and December 2014. Errors identified as “Failed Delta checks” and their root cause analyses (RCA) were reviewed.

RESULTS:

A total of 17,034 errors related to blood transfusion were reported. Of these, 38 were blood grouping errors. Seventeen blood group errors were identified due to failed delta checks, where the results of two individually drawn grouping samples yielded different blood group results. The RCA revealed that all of these errors occurred in the preanalytical phase of testing. Mislabeling resulting in wrong blood in tube was the most commonly identified cause, accounting for 11 of these errors, while problems with correct patient identification accounted for 5 failed delta checks.

CONCLUSION:

Delta checks proved to be an effective tool for detecting blood group errors and prevention of accidental mismatched blood transfusions. Preanalytical errors in patient identification or sample labeling were the most frequent.

Transfusion errors: causes, incidence, and strategies for prevention

PURPOSE OF REVIEW

Miss-transfusion of blood has become one of the leading causes of death related to blood transfusion. New technology is able to better prevent miss-transfusions than older methods.

RECENT FINDINGS

New computer-based technology is available and is very effective in preventing miss-transfusion of blood.

SUMMARY

Humans make errors. New technology can prevent those errors.

Systematic review of electronic remote blood issue

BACKGROUND AND OBJECTIVES

The implementation of electronic remote blood issue (ERBI) may provide safety and efficiency gains for transfusion medicine. This systematic review's objective was to assess whether ERBI affects incidents of adverse events, time taken for blood issue and delivery, and cross-match to transfusion ratios, among other measures of safety and efficiency. The review also sought to uncover barriers and facilitators of ERBI implementation.

MATERIALS AND METHODS

We searched four aggregated electronic databases (Medline, EMBASE, CINAHL and BIOSIS) up to 19 July 2012, with an updated search performed on 5 March 2014 for studies on ERBI. No specific study design criteria were used in the initial inclusion due to the low number of studies on ERBI.

RESULTS

A total of 4758 citations were initially identified; after 1844 duplicates were removed, 2612 citations were excluded on the basis of the abstract. Two reviewers evaluated a total of 302 full-text articles independently; of these, seven citations were eligible for inclusion. An updated search and the authors' own collections confirmed an additional five citations, totalling 13 citations and six studies within these.

CONCLUSION

There is insufficient evidence to demonstrate whether ERBI significantly impacts safety and efficiency of blood transfusion and delivery processes. Rigorously designed studies to assess safety and efficiency outcomes are required using proxy or corollary measures. A number of positive results were reported, however, and most studies included suggestions for facilitating ERBI implementation.

Phlebotomy and quality in the African laboratory

Phlebotomy, the act of drawing blood through venepuncture, is one of the most common medical procedures in healthcare, as well as being a basis for diagnosis and treatment. A review of the available research has highlighted the dearth of information on the phlebotomy practice in Africa. Several studies elsewhere have shown that the pre-analytical phase (patient preparation, specimen collection and identification, transportation, preparation for analysis and storage) is the most error-prone process in laboratory medicine. The validity of any laboratory test result hinges on specimen quality; thus, as the push for laboratory quality improvement in Africa gathers momentum, the practice of phlebotomy should be subjected to critical appraisal. This article offers several suggestions for the improvement of phlebotomy in Africa.

The role of comprehensive check at the blood bank reception on blood requisitions in detecting potential transfusion errors

Pre-transfusion testing includes proper requisitions, compatibility testing and pre-release checks. Proper labelling of samples and blood units and accurate patient details check helps to minimize the risk of errors in transfusion. This study was aimed to identify requisition errors before compatibility testing. The study was conducted in the blood bank of a tertiary care hospital in north India over a period of 3 months. The requisitions were screened at the reception counter and inside the pre-transfusion testing laboratory for errors. This included checking the Central Registration number (C.R. No.) and name of patient on the requisition form and the sample label; appropriateness of sample container and sample label; incomplete requisitions; blood group discrepancy. Out of the 17,148 blood requisitions, 474 (2.76 %) requisition errors were detected before the compatibility testing. There were 192 (1.11 %) requisitions where the C.R. No. on the form and the sample were not tallying and in 70 (0.40 %) requisitions patient's name on the requisition form and the sample were different. Highest number of requisitions errors were observed in those received from the Emergency and Trauma services (27.38 %) followed by Medical wards (15.82 %) and the lowest number (3.16 %) of requisition errors were observed from Hematology and Oncology wards. C.R. No. error was the most common error observed in our study. Thus a careful check of the blood requisitions at the blood bank reception counter helps in identifying the potential transfusion errors.

Pathogen inactivation technologies for cellular blood components: an update

Nowadays patients receiving blood components are exposed to much less transfusion-transmitted infectious diseases than three decades before when among others HIV was identified as causative agent for the acquired immunodeficiency syndrome and the transmission by blood or coagulation factors became evident. Since that time the implementation of measures for risk prevention and safety precaution was socially and politically accepted. Currently emerging pathogens like arboviruses and the well-known bacterial contamination of platelet concentrates still remain major concerns of blood safety with important clinical consequences, but very rarely with fatal outcome for the blood recipient. In contrast to the well-established pathogen inactivation strategies for fresh frozen plasma using the solvent-detergent procedure or methylene blue and visible light, the bench-to-bedside translation of novel pathogen inactivation technologies for cell-containing blood components such as platelets and red blood cells are still underway. This review summarizes the pharmacological/toxicological assessment and the inactivation efficacy against viruses, bacteria, and protozoa of each of the currently available pathogen inactivation technologies and highlights the impact of the results obtained from several randomized clinical trials and hemovigilance data. Until now in some European countries pathogen inactivation technologies are in in routine use for single-donor plasma and platelets. The invention and adaption of pathogen inactivation technologies for red blood cell units and whole blood donations suggest the universal applicability of these technologies and foster a paradigm shift in the manufacturing of safe blood.

Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors

OBJECTIVE

To determine whether the use of a computerized bar code-based blood identification system resulted in a reduction in transfusion errors or near-miss transfusion episodes.

PATIENTS AND METHODS

Our institution instituted a computerized bar code-based blood identification system in October 2006. After institutional review board approval, we performed a retrospective study of transfusion errors from January 1, 2002, through December 31, 2005, and from January 1, 2007, through December 31, 2010.

RESULTS

A total of 388,837 U were transfused during the 2002-2005 period. There were 6 misidentification episodes of a blood product being transfused to the wrong patient during that period (incidence of 1 in 64,806 U or 1.5 per 100,000 transfusions; 95% CI, 0.6-3.3 per 100,000 transfusions). There was 1 reported near-miss transfusion episode (incidence of 0.3 per 100,000 transfusions; 95% CI, <0.1-1.4 per 100,000 transfusions). A total of 304,136 U were transfused during the 2007-2010 period. There was 1 misidentification episode of a blood product transfused to the wrong patient during that period when the blood bag and patient's armband were scanned after starting to transfuse the unit (incidence of 1 in 304,136 U or 0.3 per 100,000 transfusions; 95% CI, <0.1-1.8 per 100,000 transfusions; P=.14). There were 34 reported near-miss transfusion errors (incidence of 11.2 per 100,000 transfusions; 95% CI, 7.7-15.6 per 100,000 transfusions; P<.001).

CONCLUSION

Institution of a computerized bar code-based blood identification system was associated with a large increase in discovered near-miss events.

Use of an identification system based on biometric data for patients requiring transfusions guarantees transfusion safety and traceability

BACKGROUND

One of the most serious risks of blood transfusions is an error in ABO blood group compatibility, which can cause a haemolytic transfusion reaction and, in the most severe cases, the death of the patient. The frequency and type of errors observed suggest that these are inevitable, in that mistakes are inherent to human nature, unless significant changes, including the use of computerised instruments, are made to procedures.

METHODS

In order to identify patients who are candidates for the transfusion of blood components and to guarantee the traceability of the transfusion, the Securblood system (BBS srl) was introduced. This system records the various stages of the transfusion process, the health care workers involved and any immediate transfusion reactions. The patients and staff are identified by fingerprinting or a bar code. The system was implemented within Ragusa hospital in 16 operative units (ordinary wards, day hospital, operating theatres).

RESULTS

In the period from August 2007 to July 2008, 7282 blood components were transfused within the hospital, of which 5606 (77%) using the Securblood system. Overall, 1777 patients were transfused. In this year of experience, no transfusion errors were recorded and each blood component was transfused to the right patient. We recorded 33 blocks of the terminals (involving 0.6% of the transfused blood components) which required the intervention of staff from the Service of Immunohaematology and Transfusion Medicine (SIMT). Most of the blocks were due to procedural errors.

CONCLUSIONS

The Securblood system guarantees complete traceability of the transfusion process outside the SIMT and eliminates the possibility of mistaken identification of patients or blood components. The use of fingerprinting to identify health care staff (nurses and doctors) and patients obliges the staff to carry out the identification procedures directly in the presence of the patient and guarantees the presence of the doctor at the start of the transfusion.

Consecutive national surveys of ABO-incompatible blood transfusion in Japan

BACKGROUND AND OBJECTIVES

Morbidity and mortality from ABO-incompatible transfusion persist as consequences of human error. Even so, insufficient attention has been given to improving transfusion safety within the hospital.

MATERIALS AND METHODS

National surveys of ABO-incompatible blood transfusions were conducted by the Japanese Society of Blood Transfusion, with support from the Ministry of Health, Labor and Welfare. Surveys concluded in 2000 and 2005 analysed ABO-incompatible transfusion data from the previous 5 years (January 1995 to December 1999 and January 2000 to December 2004, respectively). The first survey targeted 777 hospitals and the second, 1355 hospitals. Data were collected through anonymous questionnaires.

RESULTS

The first survey achieved a 77.4% response rate (578 of 777 hospitals). The second survey collected data from 251 more hospitals, but with a lower response rate (61.2%, or 829 of 1355 hospitals). The first survey analysed 166 incidents from 578 hospitals, vs. 60 incidents from 829 hospitals in the second survey. The main cause of ABO-incompatible transfusion was identification error between patient and blood product: 55% (91 of 166) in the first survey and 45% (27 of 60) in the second. Patient outcomes included nine preventable deaths from 1995 to 1999, and eight preventable deaths from 2000 to 2004.

CONCLUSION

Misidentification at the bedside persists as the main cause of ABO-incompatible transfusion.

Designing property specifications to improve the safety of the blood transfusion process

Computer scientists use a number of well-established techniques that have the potential to improve the safety of patient care processes. One is the formal definition of a process; the other is the formal definition of the properties of a process. Even highly regulated processes, such as laboratory specimen acquisition and transfusion therapy, use guidelines that may be vague, misunderstood, and hence erratically implemented. Examining processes in a systematic way has led us to appreciate the potential variability in routine health care practice and the impact of this variability on patient safety in the clinical setting. The purpose of this article is to discuss the use of innovative computer science techniques as a means of formally defining and specifying certain desirable goals of common, high-risk, patient care processes. Our focus is on describing the specification of process properties, that is, the high-level goals of a process that ultimately dictate why a process should be performed in a given manner.

Simplified spectraphotometric method for the detection of red blood cell agglutination

Human error is the most significant factor attributed to incompatible blood transfusions. A spectrophotometric approach to blood typing has been developed by examining the spectral slopes of dilute red blood cell (RBC) suspensions in saline, in the presence and absence of various antibodies, offering a technique for the quantitative determination of agglutination intensity [Transfusion39, 1051, 1999TRANAT0041-113210.1046/j.1537-2995.1999.39101051.x]. We offer direct theoretical prediction of the observed change in slope in the 660-1000 nm range through the use of the T-matrix approach and Lorenz-Mie theory for light scattering by dilute RBC suspensions. Following a numerical simulation using the T-matrix code, we present a simplified sensing method for detecting agglutination. The sensor design has been prototyped, fully characterized, and evaluated through a complete set of tests with over 60 RBC samples and compared with the full spectrophotometric method. The LED and photodiode pairs are found to successfully reproduce the spectroscopic determination of red blood cell agglutination.

Evaluation of a teaching pack designed for nursing students to acquire the essential knowledge for competent practice in blood transfusion administration

This article describes the evaluation of a teaching pack designed for nursing students to acquire the knowledge required for safe administration of blood transfusions. The Serious Hazards of Transfusion (SHOT) Committee is a confidential reporting body, which gathers data from the United Kingdom and reports the serious sequelae of blood transfusion. The SHOT reports have repeatedly identified that errors in blood transfusions are wholly avoidable. Nurses, as the health care professionals ultimately responsible for the bedside check, have the final opportunity to prevent a mis-transfusion [Nursing and Midwifery Council, 2004a. The NMC code of professional conduct: standards for conduct, performance and ethics. NMC, London; Serious Hazards of Transfusion, 2002. SHOT Annual Report 2001-2002. SHOT Scheme, Manchester]. The educational strategies implemented will be explained and evidence that applying structured learning programmes in the undergraduate nursing curriculum can improve students' knowledge presented. A structured questionnaire was employed to assess students' knowledge of the process for transfusing blood components pre- and post-teaching and evaluate the effectiveness of the teaching pack. The results will be presented and discussed.

Increasing patient safety and efficiency in transfusion therapy using formal process definitions

The administration of blood products is a common, resource-intensive, and potentially problem-prone area that may place patients at elevated risk in the clinical setting. Much of the emphasis in transfusion safety has been targeted toward quality control measures in laboratory settings where blood products are prepared for administration as well as in automation of certain laboratory processes. In contrast, the process of transfusing blood in the clinical setting (ie, at the point of care) has essentially remained unchanged over the past several decades. Many of the currently available methods for improving the quality and safety of blood transfusions in the clinical setting rely on informal process descriptions, such as flow charts and medical algorithms, to describe medical processes. These informal descriptions, although useful in presenting an overview of standard processes, can be ambiguous or incomplete. For example, they often describe only the standard process and leave out how to handle possible failures or exceptions. One alternative to these informal descriptions is to use formal process definitions, which can serve as the basis for a variety of analyses because these formal definitions offer precision in the representation of all possible ways that a process can be carried out in both standard and exceptional situations. Formal process definitions have not previously been used to describe and improve medical processes. The use of such formal definitions to prospectively identify potential error and improve the transfusion process has not previously been reported. The purpose of this article is to introduce the concept of formally defining processes and to describe how formal definitions of blood transfusion processes can be used to detect and correct transfusion process errors in ways not currently possible using existing quality improvement methods.

Universal pathogen-reduced plasma in elective open-heart surgery and liver resection

ABO-incompatible transfusions and transfusion-related lung injury are today the leading transfusion-related causes of death in the developed world. Since anti-A and anti-B antibodies in plasma can give rise to serious, even fatal, transfusion reactions, ABO-identical/compatible plasma is indicated, but presents a logistical challenge and a risk for transfusion of incorrect plasma. In an effort to circumvent these problems, an ABO-independent universally applicable, pathogen-reduced plasma, Uniplas, has been developed and proven safe and efficacious for use in adults through prospective, randomized, controlled open-heart surgery studies and in prospective, parallel group, controlled liver resection studies. The results of these trials are presented and discussed in relation to solvent/detergent (SD) treated plasma, in general. The cost effectiveness of pathogen-reduced plasma is low because of the very low risk for transfusion transmitted viral infections in the developed world (US 2 to 9 million dollars per quality-adjusted life year). However, taking into account the combined safety of Uniplas with regard to transfusion-related lung injury, pathogen reduction and independence of ABO blood groups, the cost per gained life year is reduced to US 40,000 dollars to 100,000 dollars.

End-to-end electronic control of the hospital transfusion process to increase the safety of blood transfusion: strengths and weaknesses

BACKGROUND

Incorrect blood component transfused is a frequent serious incident associated with transfusion and often involves misidentification of the patient and/or the unit of blood.

STUDY DESIGN AND METHODS

This study extended the evaluation of an electronic system involving bar code technology and handheld computers. Electronic control of collection of blood from blood refrigerators was incorporated into a previously described process for blood sample collection and blood administration. Practice was evaluated before and after its introduction in cardiac surgery.

RESULTS

The baseline audits revealed poor practice. Significant improvements were found following the introduction of the electronic system, including from 8 percent to 100 percent in checking that the blood group and unit number on the blood pack matched the compatibility label and the pack was in date (p < or = 0.0001). Similar significant improvements were found in blood sample collection, the collection of blood from blood refrigerators, and the documentation of transfusion. Staff found the system easy to operate and preferred it to standard procedures.

CONCLUSIONS

A bar code patient identification system improved transfusion practice, although areas for improvement were identified. These results provide support for further work on the development of such systems for both transfusion and other procedures requiring patient identification.

Reengineering transfusion and cellular therapy processes hospitalwide: ensuring the safe utilization of blood products

Efforts to make blood transfusion as safe as possible have focused on making the blood in the bag as disease-free as possible. The results have been dramatic, and the costs have been correspondingly high. Although blood services will have to continue to deal with emerging pathogens, efforts to reduce the transfusion of infectious agents presently posing a risk will require high incremental costs and result in only improvements of a small magnitude. The other aspect of safe blood transfusion, the actual transfusion process performed primarily in hospitals, has been accorded considerably less interest. We should turn our attention to enhancing overall blood safety by focusing on improving the process of blood transfusion. Errors involving patient, specimen, and blood product identification put transfused patients at risk, increasing the mortality risk for some. Solutions that could improve the transfusion process are discussed as a focus of this article.

Twelve years of the Brazilian External Quality Assessment Program in Immunohematology: benefits of the program

The Brazilian External Quality Assessment Program in Immunohematology (BEQAPI) was introduced with the objective of evaluating the quality of diagnosis in immunohematology. From 1992 to 2003, proficiency tests for ABO grouping, Rh (D, C, c, E, e), K phenotyping, direct antiglobulin testing (DAT), antibody screening (AS), and antibody identification (AI) were performed. A total of 41 evaluations were carried out in 223 institutions. Over the period of 12 years, the program included 8,014 ABO typing, 8,000 RhD typing, 5,193 Rh typing (C, c, E, e), 5,101 K phenotyping, 7,939 AS, 4,533 AI, and 7,912 DATs. Erroneous responses were classified as clerical, technical, or undetermined. A substantial proportion of erroneous responses due to clerical errors occurred in ABO typing (76/76 errors), RhD typing (34/58 errors), and Rh phenotyping (50/73 errors). Technical errors occurred predominantly for weak D (91/95 errors), AS (252/301 errors), and AI (321/335 errors). Based on these results, since 1996, participants have received "Questions and Case Studies" in Immunohematology as an incentive for training and education. The results of the present study show an improvement in the performance of participants in the course of the program. We found that a well-organized external proficiency program can contribute to the improvement of quality of testing in Immunohematology.

Universal fresh-frozen plasma (Uniplas): an exploratory study in adult patients undergoing elective liver resection

BACKGROUND AND OBJECTIVES

The compatibility of an ABO blood group independently applicable plasma, Uniplas, was explored in liver resection because patients undergoing liver resection frequently require the transfusion of plasma to compensate for blood loss and/or clotting factors.

MATERIALS AND METHODS

One-hundred and twenty two patients undergoing elective liver resection were enrolled; 81 patients required plasma transfusion, while 41 did not. Of those in need of plasma, 58 were blood group A, B or AB, and 23 were blood group O. Patients were monitored up to day 7 postoperatively for signs of haemolysis and haemostasis, and viral markers were assessed at baseline and 3 weeks postoperatively.

RESULTS

Uniplas transfusions of up to 50.7 ml/kg body weight were given per treatment episode, without signs of haemolysis caused by transfusion. A total of 94/99 patients (95%) were negative in the direct antiglobulin test throughout the study. Two patients, one transfused with Uniplas, the other not, had a positive direct antiglobulin test result at baseline, while three of 64 patients transfused with Uniplas demonstrated a change from having negative to intermittently positive direct antiglobulin test results without concurrent signs of haemolysis. International normalized ratio, activated partial thromboplastin time and protein C levels were maintained by transfusion of plasma (>/= 20 ml/kg body weight). No patient underwent seroconversion for human immunodeficiency virus, hepatitis B virus or hepatitis C virus. Positivity for hepatitis A virus (HAV) immunoglobulin G (IgG) in 11 patients from the Uniplas group (who tested HAV immunoglobulin M negative), together with an apparent seroconversion for parvovirus B19 seen in two patients who received Uniplas, indicated passively transferred IgG antibodies.

CONCLUSIONS

No haemolysis was observed as a result of Uniplas transfusions up to 50.7 ml/kg body weight per treatment episode in patients undergoing liver resection. Moreover, transfusion (>/= 20 ml/kg body weight of Uniplas) maintained acceptable levels of international normalized ratio, activated partial thromboplastin time and protein C.

Number needed to treat and cost of recombinant human erythropoietin to avoid one transfusion-related adverse event in critically ill patients

OBJECTIVE

To calculate the absolute risk reduction of transfusion-related adverse events, the number of patients needed to treat, and cost to avoid one transfusion-related adverse event by using erythropoietin in critically ill patients

DESIGN

Number needed to treat with sensitivity analysis.

SETTING

Teaching hospital.

PATIENTS

Hypothetical cohort of critically ill patients who were candidates to receive erythropoietin.

INTERVENTIONS

Using vs. not using erythropoietin to reduce the need for packed red blood cell transfusions.

MEASUREMENTS AND MAIN RESULTS

We used published estimates of known transfusion risks: transfusion-related acute lung injury, transfusion-related errors, hepatitis B and C, human immunodeficiency virus, human T-cell lymphotropic virus, and bacterial contamination, stratified by severity. Based on the estimated risk and frequency of transfusions with and without erythropoietin, we calculated the absolute risk reduction of transfusion-related adverse events, the number needed to treat, and cost to avoid one transfusion-related adverse event by using erythropoietin. The estimated incidence of transfusion-related adverse event was 318 permillion units transfused for all transfusion-related adverse events, 58 per million for serious transfusion-related adverse events, and 21 per million for likely fatal transfusion-related adverse events. The routine use of erythropoietin resulted in an absolute risk reduction of 191 per million for all transfusion-related adverse events, 35 per million for serious transfusion-related adverse events, and 12 per million for likely fatal transfusion-related adverse events. The number needed to treat was 5,246 to avoid one transfusion-related adverse event, 28,785 to avoid a serious transfusion-related adverse event, and 81,000 for a likely fatal transfusion-related adverse event. The total cost was $4,700,000 to avoid one transfusion-related adverse event, $25,600,000 to avoid one serious transfusion-related adverse event, and $71,800,000 to avoid a likely fatal transfusion-related adverse event. The magnitude of these results withstood extensive sensitivity analysis.

CONCLUSIONS

From the perspective of avoidance of adverse events, erythropoietin does not appear to be an efficient use of limited resources for routine use in critically ill patients.

Medication safety and transfusion errors in the ICU and beyond

The modern day intensive care unit (ICU) is a place in which patients can receive continuous monitoring of physiologic variables with concentrated patient observation and care. Despite the "intensive care," errors do occur. This article reviews medication and transfusion errors, including the different types, causes, and possible solutions to prevent these errors from occurring in ICUs and the hospital at large.

Barcode technology: its role in increasing the safety of blood transfusion

BACKGROUND

Incorrect blood component transfusion is the most frequent serious incident associated with transfusion. Errors responsible for these incidents frequently involve patient misidentification.

STUDY DESIGN AND METHODS

This study evaluated a barcode patient identification system involving hand-held computers for blood sample collection for compatibility testing and the administration of blood. Audit of practice was carried out before and after its introduction.

RESULTS

The baseline audit revealed poor practice, particularly in patient identification. Significant improvements were found in the procedure for the administration of blood following the introduction of barcode patient identification, including an improvement from 11.8 to 100 percent in the correct verbal identification of patients (p </= 0.001). Similar significant improvements were found in matching verbally stated identification details with details on patient identification wristbands, in correct patient identification before the collection of blood samples, and in the proportion of correctly labeled samples. Staff found the barcode identification system easy to operate and preferred it to standard procedures.

CONCLUSIONS

A barcode patient identification system was found to simplify the clinical transfusion process and improve practice. These results provide support for further work on the development of such systems for transfusion and for other hospital procedures requiring patient identification.

Evolution of quality management: integration of quality assurance functions into operations, or "quality is everyone's responsibility"

The management of quality in the Division of Transfusion Medicine at our institution has undergone a lengthy, sometimes painful but always progressive evolution over nearly four decades. Initially, it consisted of one laboratory technologist who was assigned the task of performing certain basic QC checks on a predetermined list of laboratory, collection, and processing steps. This technologist reported directly to the medical director. The tasks gradually grew in volume and complexity so that a four-person quality unit was established, administratively quite separate from the operations and accountable only to the Medical Director. The next stage in the evolutionary process was more revolutionary in scope because it involved a comprehensive cultural shift toward the concept of "quality is everyone's responsibility." The evolutionary process in our institution to date and the planning and organization involved in the direction and management of the evolution itself are described.

Human errors in medical practice: systematic classification and reduction with automated information systems

We review the general nature of human error(s) in complex systems and then focus on issues raised by Institute of Medicine report in 1999. From this background we classify and categorize error(s) in medical practice, including medication, procedures, diagnosis, and clerical error(s). We also review the potential role of software and technology applications in reducing the rate and nature of error(s).

Human error: the persisting risk of blood transfusion: a report of five cases

It is common experience that virus transmission, particularly transmission of the human immunodeficiency virus (HIV), is a principal concern of patients and physicians regarding blood transfusion (1). Many physicians are probably unaware that transfusion-transmitted HIV infection is approximately 50 to 100 times less likely to occur than transfusion error (2-4). This misconception may have been encouraged by the scarcity of reports on transfusion error relative to the tremendous public attention focused on HIV infection. We present five cases illustrating how anesthesiologists, intensivists, and emergency physicians are particularly vulnerable to the risk of administering blood to the wrong recipient. All five cases were collected during a 4-yr period. Transfused units of packed red cells totaled approximately 50,000 U during this period in our department.

IMPLICATIONS

Human error leading to the transfusion of blood to an unintended recipient is a major source of transfusion-related fatalities. We report five cases that highlight some specific areas in which transfusion error is likely to occur.

Sources of preventable errors related to transfusion

BACKGROUND AND OBJECTIVES

Transfusion errors always remain under-reported owing to a lack of awareness about transfusion-related adverse events among the hospital staff and an inadequate feedback system in most of the transfusion centres. This article reports the results obtained from a study carried out to investigate the sources and types of errors in our tertiary care hospital.

MATERIALS AND METHODS

The errors reported by the blood bank staff (i.e. reception counter clerical and technical staff) and the residents in charge of the patient, were studied over a period of 1 year (from May 1998 to April 1999) and classified based on the site of occurrence.

RESULTS

A total of 123 errors were detected over the 1-year study period. Of these 123 errors, 107 (86.99%) occurred outside the blood bank and 16 (13%) in the blood bank.

CONCLUSION

Errors occur most frequently outside the blood bank, and the bedside of the patient is the main location.