1
|
Techniques of Blood Transfusion. Transfus Med 2016. [DOI: 10.1002/9781119236504.ch13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
2
|
Recommendations for the electronic pre-transfusion check at the bedside. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:419-24. [PMID: 27136438 DOI: 10.2450/2016.0184-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 10/13/2015] [Indexed: 11/21/2022]
|
3
|
Furuta Y, Ohsawa T, Nakamura Y, Tokida M, Ichikawa K, Ohsaka A. Implementation of electronic identification system for blood transfusion in the setting of hematopoietic progenitor cell infusion at the bedside. Transfus Apher Sci 2015; 54:380-3. [PMID: 26653931 DOI: 10.1016/j.transci.2015.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 11/16/2015] [Indexed: 11/18/2022]
Abstract
Hematopoietic progenitor cell (HPC) infusion at the bedside is a critical step in HPC transplantation. In this study, we implemented a bar code-based electronic identification system (EIS) for blood transfusion in the setting of HPC infusion at the bedside. Between July 2003 and December 2014, a total of 518 HPC products were infused to 190 patients without a single misinfusion in the hospital. An overall compliance rate with the electronic pre-infusion check for HPC infusion at the bedside was 100%. Our observations suggest that an EIS can be successfully applied to the infusion of HPC products at the bedside.
Collapse
Affiliation(s)
- Yoshiaki Furuta
- Department of Transfusion Service, Juntendo University Hospital, Tokyo, Japan
| | - Toshiya Ohsawa
- Department of Transfusion Service, Juntendo University Hospital, Tokyo, Japan
| | - Yuki Nakamura
- Department of Transfusion Service, Juntendo University Hospital, Tokyo, Japan
| | - Miho Tokida
- Department of Transfusion Service, Juntendo University Hospital, Tokyo, Japan
| | - Kayoko Ichikawa
- Department of Transfusion Service, Juntendo University Hospital, Tokyo, Japan
| | - Akimichi Ohsaka
- Department of Transfusion Service, Juntendo University Hospital, Tokyo, Japan; Department of Transfusion Medicine and Stem Cell Regulation, Juntendo University School of Medicine, Tokyo, Japan.
| |
Collapse
|
4
|
|
5
|
Abstract
Virtual blood bank is the computer-controlled, electronically linked information management system that allows online ordering and real-time, remote delivery of blood for transfusion. It connects the site of testing to the point of care at a remote site in a real-time fashion with networked computers thus maintaining the integrity of immunohematology test results. It has taken the advantages of information and communication technologies to ensure the accuracy of patient, specimen and blood component identification and to enhance personnel traceability and system security. The built-in logics and process constraints in the design of the virtual blood bank can guide the selection of appropriate blood and minimize transfusion risk. The quality of blood inventory is ascertained and monitored, and an audit trail for critical procedures in the transfusion process is provided by the paperless system. Thus, the virtual blood bank can help ensure that the right patient receives the right amount of the right blood component at the right time.
Collapse
Affiliation(s)
- Kit Fai Wong
- Department of Pathology, Queen Elizabeth Hospital, Hong Kong SAR, China
| |
Collapse
|
6
|
Improved traceability and transfusion safety with a new portable computerised system in a hospital with intermediate transfusion activity. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:172-81. [PMID: 21251464 DOI: 10.2450/2011.0044-10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND A retrospective study carried out on medical records of transfused patients in our hospital in 2002 revealed that manual identification procedures were insufficient to offer satisfactory traceability. The aim of this study was to assess adequacy of transfusion traceability and compliance with proper identification procedures after introducing an electronic identification system (EIS) for transfusion safety. MATERIALS AND METHODS The chosen EIS (Gricode(®)) was set up. Traceability was calculated as the percentage of empty blood units used returned to the Transfusion Service, compared to the number of supplied units. Compliance in the Transfusion Service was calculated as the percentage of electronic controls from dispatch of blood components/transfusion request performed, compared to the total number of transfused units. Compliance in the ward was calculated as the percentage of electronic controls from sample collection/transfusion performed, compared to the total number of samples collected. RESULTS This retrospective study showed that only 48.0% of the medical records were free of inaccuracies. After the implementation of the EIS (2005-2008), traceability was always above 99%. Percentage of monthly compliance from 2006 to 2008 was always above 93%, showing a significant trend to increase (p<0.05). The mean compliance in this period was higher in the Transfusion Service (97.8 ± 0.7 SD) than in the ward (94.9 ± 2.4 SD; p<0.001). Compliance in the ward was lowest when the system was first implemented (87.9% in April 2006) after which it progressively increased. No errors in ABO transfusions were registered. CONCLUSION After implementation of the EIS, traceability and compliance reached very high levels, linked to an improvement in transfusion safety.
Collapse
|
7
|
Elhence P, Veena S, Sharma RK, Chaudhary RK. Root cause analysis of transfusion error: identifying causes to implement changes. Transfusion 2011; 50:2772-7. [PMID: 21128948 DOI: 10.1111/j.1537-2995.2010.02943.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND As part of ongoing efforts to improve transfusion safety, an error reporting system was implemented in our hospital-based transfusion medicine unit at a tertiary care medical institute. This system is based on Medical Event Reporting System-Transfusion Medicine (MERS-TM) and collects data on all near miss, no harm, and misadventures related to the transfusion process. Root cause analyses of one such innocuous appearing error demonstrate how weaknesses in the system can be identified to make necessary changes to achieve transfusion safety. STUDY DESIGN AND METHODS The reported error was investigated, classified, coded, and analyzed using MERS-TM prototype, modified and adopted for our institute. RESULTS The consequent error was a "mistransfusion" but a "no-harm event" as the transfused unit was of the same blood group as the patient. It was a high event severity level error (level 1). Multiple errors preceded the final error at various functional locations in the transfusion process. Human, organizational, and patient-related factors were identified as root causes and corrective actions were initiated to prevent future occurrences. CONCLUSION This case illustrates the usefulness of having an error reporting system in hospitals to highlight human and system failures associated with transfusion that may otherwise go unnoticed. Areas can be identified where resources need to be targeted to improve patient safety.
Collapse
Affiliation(s)
- Priti Elhence
- Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| | | | | | | |
Collapse
|
8
|
Aulbach RK, Brient K, Clark M, Custard K, Davis C, Gecomo J, Ho JO. Blood transfusions in critical care: improving safety through technology & process analysis. Crit Care Nurs Clin North Am 2010; 22:179-90. [PMID: 20541066 DOI: 10.1016/j.ccell.2010.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A multidisciplinary safety initiative transformed blood transfusion practices at St. Luke's Episcopal Hospital in Houston, Texas. An intense analysis of a mistransfusion using the principles of a Just Culture and the process of Cause Mapping identified system and human performance factors that led to the transfusion error. Multiple initiatives were implemented including technology, education and human behaviour change. The wireless technology of Pyxis Transfusion Verification by CareFusion is effective with the rapid infusion module efficient for use in critical care. Improvements in blood transfusion safety were accomplished by thoroughly evaluating the process of transfusions and by implementing wireless electronic transfusion verification technology. During the 27 months following implementation of the CareFusion Transfusion Verification there have been zero cases of transfusing mismatched blood.
Collapse
Affiliation(s)
- Rebecca K Aulbach
- Cardiovascular and Transplant Nursing, St Luke's Episcopal Hospital, 6720 Bertner Avenue, MC: 4-278, Box 76, Houston, TX 77030, USA.
| | | | | | | | | | | | | |
Collapse
|
9
|
Patients' positive identification systems. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2010; 7:313-8. [PMID: 20011643 DOI: 10.2450/2009.0001-09] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 01/15/2009] [Indexed: 11/21/2022]
Abstract
BACKGROUND Blood safety must be maintained throughout the whole transfusion chain to prevent the transfusion of incorrect blood components. The estimated risk of an incorrect transfusion is in the order of 1 per 10,000 units of blood. Although several kinds of errors contribute to "wrong blood" events, 70% of errors occur in clinical areas with the most common being due to failure of the pre-transfusion bedside checking procedure. MATERIALS AND METHODS Several methods are available to reduce such errors. The I-TRAC Plus system by Immucor consists of an identification bracelet which is a bar-coded wristband and a handheld portable computer that identifies patients and blood bags by a scanner and prints the information through a portable printer. The labels attached on the blood order forms and on the sample tubes are read and recorded in the blood bank's informatics system (EmoNet INSIEL). Labels showing the bar-code of the assigned number, which includes the ID number of the patient, the ID number of the unit and a code identifying the kind of product and use (allogeneic or autologous), are generated and applied to the blood components. The transfusions are administered after checking the unit and the patient's wristband using the scanner of a portable PC. RESULTS In 5 years a total of 71,400 units of blood components were transfused to 15,430 patients using the I-TRAC Plus system. The system prevented 12 cases of mis-identification of patients (5 in 2003, 0 in 2004, 1 in 2005, 1 in 2006 and 5 in 2007). CONCLUSIONS In 2003 we introduced the use of a bar-code matching system between a patient's wristband and the blood bag to avoid mistakes at the bedside. In 5 years the system provided benefits by avoiding errors in the identification of patients, thus preventing "wrong blood" transfusions.
Collapse
|
10
|
|
11
|
Goodnough LT, Viele M, Fontaine MJ, Jurado C, Stone N, Quach P, Chua L, Chin ML, Scott R, Tokareva I, Tabb K, Sharek PJ. Implementation of a two-specimen requirement for verification of ABO/Rh for blood transfusion. Transfusion 2009; 49:1321-8. [DOI: 10.1111/j.1537-2995.2009.02157.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
12
|
Bennardello F, Fidone C, Cabibbo S, Calabrese S, Garozzo G, Cassarino G, Antolino A, Tavolino G, Zisa N, Falla C, Drago G, Di Stefano G, Bonomo P. Use of an identification system based on biometric data for patients requiring transfusions guarantees transfusion safety and traceability. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2009; 7:193-203. [PMID: 19657483 PMCID: PMC2719271 DOI: 10.2450/2009.0067-08] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 01/16/2009] [Indexed: 11/21/2022]
Abstract
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.
Collapse
|
13
|
Fujii Y, Shibata Y, Miyata S, Inaba S, Asai T, Hoshi Y, Takamatsu J, Takahashi K, Ohto H, Juji T, Sagawa K. Consecutive national surveys of ABO-incompatible blood transfusion in Japan. Vox Sang 2009; 97:240-6. [PMID: 19476605 DOI: 10.1111/j.1423-0410.2009.01199.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- Y Fujii
- Department of Blood Transfusion, Yamaguchi University Hospital, Yamaguchi, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Ohsaka A, Abe K, Ohsawa T, Miyake N, Sugita S, Tojima I. A computer-assisted transfusion management system and changed transfusion practices contribute to appropriate management of blood components. Transfusion 2008; 48:1730-8. [PMID: 18482189 DOI: 10.1111/j.1537-2995.2008.01744.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND ABO-incompatible blood transfusions attributable to inadequate identification (ID) of the patient or the blood unit are among the most serious of transfusion hazards. It has been unclear whether a computer-assisted transfusion management system connected to a bar code ID system could contribute to the appropriate management of blood components, as well as to the prevention of mistransfusions. STUDY DESIGN AND METHODS A transfusion management system has been developed that links the hospital information system, a bar code patient-blood unit ID system, and an automated device for pretransfusion testing. The guidelines for issuing blood components from the transfusion service were also changed. The appropriateness of blood management was evaluated by monitoring the time to initiate transfusion after issuing a blood unit from the transfusion service (time after issuing [TAI]) and by calculating the number of units issued and subsequently returned, as well as the rate of date-expired red cell (RBC) components. RESULTS From July 2002 to December 2006, a total of 49,974 blood components were transfused without a single mistransfusion. The monitoring of TAI and the notice to use the issued blood immediately had the effect of shortening TAI in the inpatient ward. The number of issued and subsequently returned RBC components, as well as the rate of date-expired RBC components, decreased significantly after the introduction of the system. CONCLUSION A computer-assisted transfusion management system and changing transfusion practices appear useful in preventing mistransfusions and in contributing to the appropriate management of blood components.
Collapse
Affiliation(s)
- Akimichi Ohsaka
- Department of Transfusion Medicine and Stem Cell Regulation, Juntendo University School of Medicine, Tokyo, Japan.
| | | | | | | | | | | |
Collapse
|
15
|
Askeland R, McGrane S, Levitt J, Dane S, Greene D, VandeBerg J, Walker K, Porcella A, Herwaldt L, Carmen L, Kemp J. Improving transfusion safety: implementation of a comprehensive computerized bar codebased tracking system for detecting and preventing errors. Transfusion 2008; 48:1308-17. [DOI: 10.1111/j.1537-2995.2008.01668.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
16
|
Quality Improvement Opportunities in Blood Banking and Transfusion Medicine. Clin Lab Med 2008; 28:321-37, viii. [DOI: 10.1016/j.cll.2007.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
17
|
Aandahl GS, Knutsen TR, Nafstad K. Implementation of ISBT 128, a quality system, a standardized bar code labeling of blood products worldwide, electronic transfusion pathway: four years of experience in Norway. Transfusion 2007; 47:1674-8. [PMID: 17725733 DOI: 10.1111/j.1537-2995.2007.01340.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND In today's world of multinational disaster relief programs, blood collected and processed in one country may be used in another. A great deal of important information is carried by a blood product label. Given the concerns about safety and traceability, it is important to use globally unique blood product coding and labeling system. STUDY DESIGN AND METHODS In 1994 the International Society of Blood Transfusion (ISBT) gave a group, ICCBBA (formerly called International Council for Commonality in Blood Banking Automation), the responsibility for implementing a new, safe international system for coding and labeling blood products. This new system is based on 128 bar code symbology and is called ISBT 128. This study describes how ISBT 128 was implemented in blood banks in Norway. RESULTS As soon as a couple of the most central blood banks implemented the system and started to use it in 2001, they found that it was much easier to handle than their old systems. There were two different software systems being used that were ISBT 128-compliant. The facilities started to export and import blood products to each other. The "foreign" blood products were easily scanned into "own" inventory. They were reluctant to order blood products from blood banks not using ISBT 128. Because of the success in the Department of Immunology and Transfusion Medicine at the University Hospital of Akershus and some other blood banks in Norway, the Norwegian Health Authorities advised all the blood banks to implement ISBT 128. CONCLUSION The use of ISBT 128 has been a success from the very beginning.
Collapse
Affiliation(s)
- Gerd Selset Aandahl
- Department of Immunology and Transfusion Medicine, Akershus University Hospital, Lørenskog, Norway.
| | | | | |
Collapse
|
18
|
Abstract
Recent reports from different haemovigilance systems indicate that errors in the whole-blood transfusion chain - from initial recipient identification to final blood administration - occur with a frequency of approximately 1 in 1000 events. Although mistakes occur also within the blood transfusion service, about two-thirds of errors are associated with incorrect blood recipient identification at the patient's bedside. To prevent the potentially fatal consequences of such mistakes, specific tools have been developed, including patient identification bracelets with barcodes and/or radio frequency identification devices, mechanical or electronic locks preventing access to bags assigned to other patients, and palm computers suitable for transferring blood request and administration data from the patient's bedside to the blood transfusion service information system in real time. The effectiveness of these systems in preventing mistransfusion has been demonstrated in a number of studies.
Collapse
Affiliation(s)
- P Pagliaro
- Centro Trasfusionale, Ospedale Carlo Poma, Mantua, Italy.
| | | |
Collapse
|
19
|
Brooks JP. Reengineering transfusion and cellular therapy processes hospitalwide: ensuring the safe utilization of blood products. Transfusion 2005; 45:159S-71S. [PMID: 16181401 DOI: 10.1111/j.1537-2995.2005.00617.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jay P Brooks
- University of Oklahoma Health Sciences Center and Department of Veterans Affairs Medical Center, Oklahoma City, OK 73104, USA
| |
Collapse
|
20
|
Abstract
PURPOSE OF REVIEW Errors related to blood transfusion in hospitals may produce catastrophic consequences. This review addresses potential solutions to prevent patient misidentification including the use of new technology, such as barcoding. RECENT FINDINGS A small number of studies using new technology for the transfusion process in hospitals have shown promising results in preventing errors. The studies demonstrated improved transfusion safety and staff preference for new technology such as bedside handheld scanners to carry out pretransfusion bedside checking. They also highlighted the need for considerable efforts in the training of staff in the new procedures before their successful implementation. SUMMARY Improvements in hospital transfusion safety are a top priority for transfusion medicine, and will depend on a combined approach including a better understanding of the causes of errors, a reduction in the complexity of routine procedures taking advantage of new technology, improved staff training, and regular monitoring of practice. The use of new technology to improve the safety of transfusion is very promising. Further development of the systems is needed to enable staff to carry out bedside transfusion procedures quickly and accurately, and to increase their functionality to justify the cost of their wider implementation.
Collapse
Affiliation(s)
- M F Murphy
- National Blood Service, John Radcliffe Hospital, Oxford, UK.
| | | |
Collapse
|