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

Electronic prescription of Labile Blood Products: A cultural revolution by the APHM and EFS PACA-Corsica!

The electronic prescription of Labile Blood Products was recommended in a 1997 directive, to ensure transfusion safety in healthcare services. Following multiple institutional reminders by the Haemovigilance Unit of the Marseille Public Hospitals (APHM), the board of directors decided to set up a project for electronic transfusion records. Here we present the issues arising from this computerisation and the impact of this change of practice on the APHM and the Etablissement Français du Sang PACA-Corse (EFS PACA-Corsica; French Blood Institute Provence-Alpes-Côte d'Azur-Corsica). Concerning the APHM, we were overly optimistic when designing the prescription of Labile Blood Products (LBP), thinking that prescribers would choose the correct product qualifications. Unfortunately, the choice of LBP qualifications was excessive, resulting in product reception being blocked for the medical units. Furthermore, we were also faced with a resistance to change from the older doctors, while the younger doctors and junior doctors at ease with computers rapidly adhered to the tool. Concerning the EFS PACA-Corsica, this change in practice disconnected the link between the software in charge of red cell immunohaematology and LBP delivery, requiring the development of a new tool to re-establish a link. The EFS demanded a remote print-out, as a back-up for the electronic delivery of the prescription. The issue around identity discordance reinforced the ties between the APHM Haemovigilance and Identity Vigilance Units and the EFS. The partnership between our two structures was beneficial for the implementation of electronic transfusion records. The APHM gained in safety, obliging prescribers to note the duration of transfusion, and in healthcare traceability (reception, transfusion, adverse event reporting etc.). For the EFS PACA-Corsica, despite the difficulties encountered with software when the tool was first implemented, electronic nominative prescription made tasks simpler, gave better access to transfusion data, and reduced the number of phone calls from medical units inquiring about patient immunohaematology results. The comprehension and attentiveness between our two entities enabled us to complete this project and to resolve the problems as they appeared.

The impact of a closed-loop electronic blood transfusion system on transfusion errors and staff time in a children's hospital

OBJECTIVES

- To assess the impact of a closed-loop electronic blood transfusion system on transfusion errors and staff time.

MATERIALS AND METHODS

- Before and after study in all wards of a children's hospital, involving patients and staff of all the wards. The changes were closed-loop electronic blood transfusion, barcode patient identification, electronic blood transfusion administration records and error pop-up warning. The main outcome measures were percentage of blood transfusion errors, time spent on transfusion tasks.

RESULTS

- Transfusion errors were identified in 3.87% of 2556 blood transfusion orders pre-intervention and 0.78% of 2577 orders afterwards (P<0.01). Phlebotomists, nurses, and physicians may make mistakes, including wrong blood type when apply for blood, wrong patient when blood draw or transfusion, wrong dose when apply for blood and the wrong tube label when blood draw or cross-matching, which are significantly reduced after change (1.09% vs 0.31%, 1.13% vs 0%, 0.31% vs 0%, 1.33% vs.0.78%, P<0.01). Time spent on blood apply was 5.3±1.2 min, hand over blood bag at the transfusion department was 14.9±1.4 min and blood transfusion was 15.8±2.4 min. Time per transfusion round decreased to 2.6±1.0 min, 6.3±1.6 min and 9.3±2.2 min respectively (P<0.01).

CONCLUSIONS

- A closed-loop electronic blood transfusion, barcode patient identification and error pop-up warning reduced transfusion errors, and increased confirmation of patient and blood types identity before transfusion. Time spent on blood transfusion tasks reduced.

A review of electronic medical records and safe transfusion practice for guideline development

BACKGROUND AND OBJECTIVES

Electronic medical records (EMRs) are often composed of multiple interlinking systems, each serving a particular task, including transfusion ordering and administration. Transfusion may not be prioritized when developing or implementing electronic platforms. Uniform guidelines may assist information technology (IT) developers, institutions and healthcare workforces to progress with shared goals.

MATERIALS AND METHODS

A narrative review of current clinical guidance, benefits and risks of electronic systems for clinical transfusion practice was combined with feedback from experienced transfusion practitioners.

RESULTS

There is opportunity to improve the safety, quality and efficiency of transfusion practice, particularly through decision support and better identification procedures, by incorporating transfusion practice into EMRs. However, these benefits should not be assumed, as poorly designed processes within the electronic systems and the critically important electronic-human process interfaces may increase risk while creating the impression of safety.

CONCLUSION

Guidelines should enable healthcare and IT industries to work constructively together so that each implementation provides assurance of safe practice.

A novel approach to bedside pretransfusion identity check of blood and its components: the Sandesh Positive-Negative protocol

Background

Blood component mistransfusion is generally due to preventable clerical errors, specifically pretransfusion misidentification of patient/blood unit at bedside. Hence, electronic devices such as barcode scanners are recommended as the standard instrument used to check the patient’s identity. However, several healthcare facilities in underdeveloped countries cannot afford this instrument; hence, they usually perform subjective visual assessment to check the patient’s identity. This type of assessment is prone to clinical errors, which precipitates significant level of anxiety in the healthcare personnel transfusing the blood unit. Hence, a novel objective method in performing pretransfusion identity check, the ‘Sandesh Positive-Negative (SPON) protocol,’ was developed.

Methods

A nonrandomized study on bedside pretransfusion identity check was conducted, and 75 health care personnel performed transfusion. The intervention was performed by matching a custom-made negative label with blood component with the positive label of the same patient available at bedside who was about to receive transfusion.

Results

In total, 85.3% of the subjects were anxious while performing pretransfusion identity check based on the existing standard practice. After the implementation of the SPON protocol, only 38.7% experienced either mild, moderate or severe anxiety. The overall level of satisfaction also increased from 8.0% to 38.7% and none were dissatisfied. Although only 9.3% were dissatisfied about the existing practice, approximately 70.7% felt the need for a better/additional protocol. Clerical error was not observed.

Conclusions

The SPON protocol is a cost-effective objective method that reduces anxiety and increases satisfaction levels when performing final bedside identity check of blood components.

Performance Evaluation of Automated Immunohematology Analyzer IH-500 for Blood Bank Testing

The automated immunohematology analyzer IH-500 (Bio-rad, Cressier FR, Switzerland) was developed recently for blood bank tests and this study evaluated performance of IH-500. 200 blood samples for ABO/Rh typing were collected. ABO/Rh typing results measured by IH-500 was compared with conventional manual methods. Antibody screening tests were performed with 100 samples using both IH-500 and the Ortho BioVue System, and results were compared. Antibody identification tests were conducted on 5 samples using both IH-500 and the Ortho BioVue System and results were compared. Crossmatching was performed with both IH-500 and conventional manual tube method using 4 patient serum samples and 10 blood cell donors, and 40 results were compared. Isoagglutinin titer of anti-A and anti-B was determined in 10 samples using both IH-500 and the automated analyzer Ortho AutoVue Innova and concordance rates were obtained. The concordance rates of ABO/Rh typing, antibody screening test, antibody identification test, and crossmatching between comparative manual methods and the IH-500 were all 100%. In the evaluation of isoagglutinin titer, 8 (80.0%) results out of 10 samples (80%) showed results within ± 1 titer between the IH-500 and the AutoVue Innova, which indicates the concordance rates of 80.0%. IH-500 reported results with two titers lower than Ortho AutoVue Innova in two samples. The IH-500 demonstrated good concordance rates and provided reliable results compared to comparative manual methods in the blood bank testing. IH-500 would be useful as a possible replacement for conventionally performed manual methods in blood bank testing.

Sample collection and sample handling errors submitted to the transfusion error surveillance system, 2006 to 2015

BACKGROUND

In Canada, transfusion-related errors are voluntarily reported to a tracking system with the goal to systematically improve transfusion safety. This report provides an analysis of sample collection (SC) and sample handling (SH) errors from this national error-tracking system.

STUDY DESIGN AND METHODS

Errors from 2006 to 2015 from 23 participating sites were extracted. A survey was conducted to obtain information regarding institutional policies. Samples received in the blood bank were used to calculate rates. "Wrong blood in tube" (WBIT) errors are blood taken from wrong patient and labeled with intended patient's information, or blood taken from intended patient but labeled with another patient's information.

RESULTS

A total of 42,363 SC and 14,666 SH errors were reported. Predefined low-severity (low potential for harm) and high-severity errors (potential for fatal outcomes) increased from 2006 to 2015 (low SC, SH: 13-27, 3-12 per 1000; high SC, SH: 1.9-3.7, 0.5-2.0 per 1000). The WBIT rate decreased from 12 to 5.8 per 10,000 between 2006 and 2015 (p < 0.0001). The overall WBIT rate was 6.2 per 10,000, with variability by site (median, 0.3 per 10,000; range, 0-17 per 10,000). Sites with error detection mechanisms, such as regrouping second sample requirements, had lower error rates than sites that did not (SC, SH: 12, 1 per 1000 samples vs. 17, 3 per 1000 samples; p < 0.0001).

CONCLUSION

WBIT rates decreased significantly. Low-severity error rates are climbing likely due to increased ascertainment and reporting. Prevention studies are necessary to inform changes to blood transfusion standards to eliminate these errors.

Can mHealth improve access to safe blood for transfusion during obstetric emergency?

PURPOSE

Of the 99% maternal deaths that take place in developing countries, one-fourth is due to postpartum hemorrhage (PPH). PPH accounts for one-third of all blood transfusions in Bangladesh where the transfusion process is lengthy as most facilities do not have in-house blood bank facilities. In this context, the location where blood is obtained and the processes of obtaining blood products are not standardized, leading to preventable delays in collecting blood, when it is needed. This study evaluated the effectiveness of an online Blood Information Management Application (BIMA) system for reducing lag time in the blood transfusion process.

PATIENTS AND METHODS

The study was conducted in a public medical college hospital in Dhaka, Bangladesh, and in two proximate, licensed blood banks between January 2014 and March 2015, using a before after design. A total of 310 women (143 before and 177 after), who needed emergency blood transfusion during their perinatal period, as determined by a medical professional, were included in the study. A median linear regression model was employed to assess the adjusted effect of BIMA on transfusion time.

RESULTS

After the introduction of BIMA, the median duration between the identified need for blood and blood transfusion reduced from 152 to 122 minutes (P<0.05). For PPH specifically, the reduction was from 175 to 113 minutes (P<0.05). After introducing BIMA and after adjusting for criteria such as maternal age, education, parity, duty roster of providers, and reasons for blood transfusion, a 24 minute reduction in the time was observed between the identified need for blood and transfusion (P<0.001).

CONCLUSION

BIMA was effective in reducing delays in blood transfusion for emergency obstetric patients. This pilot study suggests that implementing BIMA is one mechanism that has the potential to streamline blood transfusion systems in Bangladesh.

Blood sampling - Two sides to the story

This study aimed to investigate why there is variability in taking blood. A multi method Pilot study was completed in four National Health Service Scotland hospitals. Human Factors/Ergonomics principles were applied to analyse data from 50 observations, 15 interviews and 12-months of incident data from all Scottish hospitals. The Functional Resonance Analysis Method (FRAM) was used to understand why variability may influence blood sampling functions. The analysis of the 61 pre blood transfusion sampling incidents highlighted limitations in the data collected to understand factors influencing performance. FRAM highlighted how variability in the sequence of blood sampling functions and the number of practitioners involved in a single blood sampling activity was influenced by the working environment, equipment, clinical context, work demands and staff resources. This pilot study proposes a realistic view of why blood sampling activities vary and proposes the need to consider the system's resilience in future safety management strategies.

Blood Bank Specimen Mislabeling: A College of American Pathologists Q-Probes Study of 41 333 Blood Bank Specimens in 30 Institutions

Context.—Incorrectly labeled patient blood specimens create opportunities for laboratory testing personnel to mistake one patient's specimen for a specimen from a different patient. Transfusion of blood that is typed on specimens that are mislabeled can result in acute hemolytic transfusion reactions.

Objective.—To assess the rates of blood bank ABO typing specimens that are mislabeled and/or contain blood belonging to another patient (so-called wrong blood in tube [WBIT]), and to compare these rates with those determined in a similar study performed in 2007.

Design.—Participants enrolled in this College of American Pathologists Q-Probes study for the first quarter of 2015 tallied the number of mislabeled and WBIT ABO blood typing specimens. Outcome measurements were the number of mislabeled and WBIT instances per 1000 specimens. We also evaluated the effects of various practice characteristics, in particular the use of bar coding, on the outcome measurements.

Results.—A total of 30 institutions submitting data on 41 333 ABO blood typing specimens recorded aggregate rates of 7.4 instances of mislabeling (306 specimens) and 0.43 instances of WBIT (10 of 23 234) per 1000 specimens submitted. Mislabeling rates were lower in institutions requiring that specimens be labeled with patients' birth dates than those that did not. The rates of specimen mislabeling and WBIT were otherwise unassociated with any of the other practice variables evaluated.

Conclusions.—The rates of ABO blood typing specimen mislabeling and WBIT are not statistically different from those determined in a similar study performed in 2007 (P = .94 and P = .10). The use of bar coding was not associated with lower mislabeling (P = .80) or WBIT rates (P = .79).

Comparative Analysis of Clinical Samples Showing Weak Serum Reaction on AutoVue System Causing ABO Blood Typing Discrepancies

Background

ABO blood typing in pre-transfusion testing is a major component of the high workload in blood banks that therefore requires automation. We often experienced discrepant results from an automated system, especially weak serum reactions. We evaluated the discrepant results by the reference manual method to confirm ABO blood typing.

Methods

In total, 13,113 blood samples were tested with the AutoVue system; all samples were run in parallel with the reference manual method according to the laboratory protocol.

Results

The AutoVue system confirmed ABO blood typing of 12,816 samples (97.7%), and these results were concordant with those of the manual method. The remaining 297 samples (2.3%) showed discrepant results in the AutoVue system and were confirmed by the manual method. The discrepant results involved weak serum reactions (<2+ reaction grade), extra serum reactions, samples from patients who had received stem cell transplants, ABO subgroups, and specific system error messages. Among the 98 samples showing ≤1+ reaction grade in the AutoVue system, 70 samples (71.4%) showed a normal serum reaction (≥2+ reaction grade) with the manual method, and 28 samples (28.6%) showed weak serum reaction in both methods.

Conclusions

ABO blood tying of 97.7% samples could be confirmed by the AutoVue system and a small proportion (2.3%) needed to be re-evaluated by the manual method. Samples with a 2+ reaction grade in serum typing do not need to be evaluated manually, while those with ≤1+ reaction grade do.

An experience of the introduction of a blood bank automation system (Ortho AutoVue Innova) in a regional acute hospital

This paper reports on an evaluation of the introduction of a blood bank automation system (Ortho AutoVue(®) Innova) in a hospital blood bank by considering the performance and workflow as compared with manual methods. The turnaround time was found to be 45% faster than the manual method. The concordance rate was found to be 100% for both ABO/Rh(D) typing and antibody screening in both of the systems and there was no significant difference in detection sensitivity for clinically significant antibodies. The Ortho AutoVue(®) Innova automated blood banking system streamlined the routine pre-transfusion testing in hospital blood bank with high throughput, equivalent sensitivity and reliability as compared with conventional manual method.

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.

Automated point-of-care testing for ABO agglutination test: proof of concept and validation

BACKGROUND AND OBJECTIVES

ABO-incompatible red blood cell transfusions still represent an important hazard in transfusion medicine. Therefore, some countries have introduced a systematic bedside ABO agglutination test checking that the right blood is given to the right patient. However, this strategy requires an extremely time-consuming learning programme and relies on a subjective interpretation of ABO test cards agglutination. We developed a prototype of a fully automated device performing the bedside agglutination test that could be completed by reading of a barcoded wristband. This POCT checks the ABO compatibility between the patient and the blood bag.

MATERIALS AND METHODS

Proof of concept and analytical validation of the prototype has been completed on 451 blood samples: 238 donor packed red blood cells, 137 consecutive unselected patients for whom a blood group determination had been ordered and on 76 patient samples selected with pathology that could possibly interfere with or impair performances of the assay.

RESULTS

We observed 100% concordance for ABO blood groups between the POCT and the laboratory instrument.

CONCLUSION

These preliminary results demonstrate the feasibility of ABO determination with a simple POCT device eliminating manipulation and subjective interpretation responsible for transfusion errors. This device should be linked to the blood bank system allowing all cross-check of the results.

Simulation training improves clinical knowledge of major haemorrhage management in foundation year doctors

OBJECTIVES

(i) To develop a major haemorrhage simulation training programme. (ii) To design an assessment tool to measure the effectiveness of this programme. (iii) To use simulation training to create more effective protocols.

BACKGROUND

Major haemorrhage is a time-critical medical emergency that can be faced by every Foundation Year (FY) doctor. Standard methods of teaching provide limited opportunity for junior doctors to improve their knowledge and practical skills for major haemorrhage situations. Simulation is increasingly used in medical training but has not been used as a means both to facilitate learning and refine hospital major haemorrhage policy.

METHODS

The effect of major haemorrhage simulation on attendees' learning was compared to a comparator group not exposed to simulation. Questionnaire pre-simulation and 3 months post-simulation training assessed knowledge of the Trust Major Haemorrhage Protocol (MHP).

RESULTS

Sixteen FY1 doctors attended simulation training. The comparator group included 47 FY1 doctors. No significant difference was found between simulation and comparator groups on baseline questionnaire scores. The simulation group showed significant improvement (total score, mean standard deviation (SD) pre-test 27.15 (4.02), post-test 39.13 (3.91), p < 0.001). The comparator group showed no significant change (total score, pre-test 25.06 (5.70), post-test 23.54 (6.85), p = 0.33) (19 lost to follow up). The study resulted in the production of a new MHP.

CONCLUSION

This study has demonstrated that simulation training improved doctors' knowledge in major haemorrhage management and that the experience of observing the simulation training allowed senior staff to undertake analysis and improvement of an existing MHP.

Wrong blood in tube - potential for serious outcomes: can it be prevented?

'Wrong blood in tube' (WBIT) errors, where the blood in the tube is not that of the patient identified on the label, may lead to catastrophic outcomes, such as death from ABO-incompatible red cell transfusion. Transfusion is a multistep, multidisciplinary process in which the human error rate has remained unchanged despite multiple interventions (education, training, competency testing and guidelines). The most effective interventions are probably the introduction of end-to-end electronic systems and a group-check sample for patients about to receive their first transfusion, but neither of these eradicates all errors. Further longer term studies are required with assessment before and after introduction of the intervention. Although most focus has been on WBIT in relation to blood transfusion, all pathology samples should be identified and linked to the correct patient with the same degree of care. Human factors education and training could help to increase awareness of human vulnerability to error, particularly in the medical setting where there are many risk factors.

Interventions to reduce wrong blood in tube errors in transfusion: a systematic review

This systematic review addresses the issue of wrong blood in tube (WBIT). The objective was to identify interventions that have been implemented and the effectiveness of these interventions to reduce WBIT incidence in red blood cell transfusion. Eligible articles were identified through a comprehensive search of The Cochrane Library, MEDLINE, EMBASE, Cinahl, BNID, and the Transfusion Evidence Library to April 2013. Initial search criteria were wide including primary intervention or observational studies, case reports, expert opinion, and guidelines. There was no restriction by study type, language, or status. Publications before 1995, reviews or reports of a secondary nature, studies of sampling errors outwith transfusion, and articles involving animals were excluded. The primary outcome was a reduction in errors. Study characteristics, outcomes measured, and methodological quality were extracted by 2 authors independently. The principal method of analysis was descriptive. A total of 12,703 references were initially identified. Preliminary secondary screening by 2 reviewers reduced articles for detailed screening to 128 articles. Eleven articles were eventually identified as eligible, resulting in 9 independent studies being included in the review. The overall finding was that all the identified interventions reduced WBIT incidence. Five studies measured the effect of a single intervention, for example, changes to blood sample labeling, weekly feedback, handwritten transfusion requests, and an electronic transfusion system. Four studies reported multiple interventions including education, second check of ID at sampling, and confirmatory sampling. It was not clear which intervention was the most effective. Sustainability of the effectiveness of interventions was also unclear. Targeted interventions, either single or multiple, can lead to a reduction in WBIT; but the sustainability of effectiveness is uncertain. Data on the pre- and postimplementation of interventions need to be collected in future trials to demonstrate effectiveness, and comparative studies are needed of different interventions.

Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety

The Serious Hazards of Transfusion (SHOT) UK confidential haemovigilance reporting scheme began in 1996. Over the 16 years of reporting, the evidence gathered has prompted changes in transfusion practice from the selection and management of donors to changes in hospital practice, particularly better education and training. However, half or more reports relate to errors in the transfusion process despite the introduction of several measures to improve practice. Transfusion in the UK is very safe: 2·9 million components were issued in 2012, and very few deaths are related to transfusion. The risk of death from transfusion as estimated from SHOT data in 2012 is 1 in 322 580 components issued and for major morbidity, 1 in 21 413 components issued; the risk of transfusion-transmitted infection is much lower. Acute transfusion reactions and transfusion-associated circulatory overload carry the highest risk for morbidity and death. The high rate of participation in SHOT by National Health Service organizations, 99·5%, is encouraging. Despite the very useful information gained about transfusion reactions, the main risks remain human factors. The recommendations on reduction of errors through a ‘back to basics’ approach from the first annual SHOT report remain absolutely relevant today.

[Qualitative evaluation of blood products records in a hospital]

PURPOSE OF THE STUDY

This study aimed at evaluating the qualitative performance of blood products traceability from paper and electronic medical records in a hospital.

STUDY DESIGN

Quality of date/time documentation was assessed by detection, for 20minutes or more, of chronological errors and inter-source inconsistencies, in a random sample of 168 blood products transfused during 2009.

RESULTS

A receipt date/time was confirmed in 52% of paper records; a data entry error was attested in 25% of paper records, and 21% of electronic records. A transfusion date/time was notified in 93% of paper records, with a data entry error in 26% of paper records and 25% of electronic records. The patient medical record held at least one date/time error in 18% and 17%, for receipt and transfusion respectively. Environmental factors (clinical setting, urgency, blood product category) did not contributed to data error rates.

CONCLUSION

Although blood products traceability has good quantitative results, the recorded documentation is not qualitative. In our study, data entry errors are similar in electronic or paper records, but the global failure rate is lesser in electronic records because omissions are controlled.

Virtual blood bank

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.

Blood transfusions in critical care: improving safety through technology & process analysis

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.

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration

CONTEXT

Mislabeled laboratory specimens are a common source of harm to patients, such as repeat phlebotomy; repeat diagnostic procedure, including tissue biopsy; delay in a necessary surgical procedure; and the execution of an unnecessary surgical procedure. Mislabeling has been estimated to occur at a rate of 0.1% of all laboratory and anatomic pathology specimens submitted.

OBJECTIVE

To identify system vulnerabilities in specimen collection, processing, analysis, and reporting associated with patient misidentification involving the clinical laboratory, anatomic pathology, and blood transfusion services.

DESIGN

A qualitative analysis was performed on 227 root cause analysis reports from the Veterans Health Administration. Content analysis of case reports from March 9, 2000, to March 1, 2008, was facilitated by a Natural Language Processing program. Data were categorized by the 3 stages of the laboratory test cycle.

RESULTS

Patient misidentification accounted for 182 of 253 adverse events, which occurred in all 3 stages of the test cycle. Of 132 misidentification events occurring in the preanalytic phase, events included wrist bands labeled for the wrong patient were applied on admission (n = 8), and laboratory tests were ordered for the wrong patient by selecting the wrong electronic medical record from a menu of similar names and Social Security numbers (n = 31). Specimen mislabeling during collection was associated with "batching" of specimens and printed labels (n = 35), misinformation from manual entry on laboratory forms (n = 14), failure of 2-source patient identification for clinical laboratory specimens (n = 24), and failure of 2-person verification of patient identity for blood bank specimens (n = 20). Of 37 events in the analytic phase, relabeling all specimens with accession numbers was associated with mislabeled specimen containers, tissue cassettes, and microscopic slides (n = 27). Misidentified microscopic slides were associated with a failure of 2-pathologist verification for cancer diagnosis (n = 4), and wrong patient transfusions were associated with mislabeled blood products (n = 3) and a failure of 2-person verification for blood products before release by the blood bank (n = 3). There were 13 events in the postanalytic phase in which results were reported into the wrong patient medical record (n = 8), and incompatible blood transfusions were associated with failed 2-person verification of blood products (n = 5).

CONCLUSIONS

Patient misidentification in the clinical laboratory, anatomic pathology, and blood transfusion processes were due to a limited set of causal factors in all 3 phases of the test cycle. A focus on these factors will inform systemic mitigation and prevention strategies.

Health economics of blood transfusion safety--focus on sub-Saharan Africa

BACKGROUND AND OBJECTIVES

Health economics provides a standardised methodology for valid comparisons of interventions in different fields of health care. This review discusses the health economic evaluations of strategies to enhance blood product safety in sub-Saharan Africa.

METHODS

We reviewed health economic methodology with special reference to cost-effectiveness analysis. We searched the literature for cost-effectiveness in blood product safety in sub-Saharan Africa.

RESULT

HIV-antibody screening in different settings in sub-Saharan Africa showed health gains and saved costs. Except for adding HIV-p24 screening, adding other tests such as nucleic acid amplification testing (NAT) to HIV-antibody screening displayed incremental cost-effectiveness ratios greater than the WHO/World Bank specified threshold for cost-effectiveness. The addition of HIV-p24 in combination with HCV antibody/antigen screening and multiplex (HBV, HCV and HIV) NAT in pools of 24 may also be cost-effective options for Ghana.

CONCLUSIONS

From a health economic viewpoint, HIV-antibody screening should always be implemented in sub-Saharan Africa. The addition of HIV-p24 antigen screening, in combination with HCV antibody/antigen screening and multiplex (HBV, HCV and HIV) NAT in pools of 24 may be feasible options for Ghana. Suggestions for future health economic evaluations of blood transfusion safety interventions in sub-Saharan Africa are: mis-transfusion, laboratory quality and donor management.

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.

Causes of failure of a barcode-based pretransfusion check at the bedside: experience in a university hospital

SUMMARY

The objective of this study was to assess the cause of failure of bedside barcode identification before blood administration. The bedside check is the most critical step for prevention of mistransfusion. A barcode patient-blood unit identification system was implemented in all inpatient wards, operating rooms and an outpatient haematology unit in July 2002. The transfusion service monitored compliance with bedside barcode identification and checked it at 24 h or 1 h after issuing of blood. If electronic checking was not completed at that time, the transfusion service clarified the cause of failure and indicated the immediate use of the issued blood when it was not yet transfused. From April 2004 to December 2007, a total of 43 068 blood components were transfused without a single mistransfusion and 958 transfusions (2.2%) were performed without electronic checking. The overall compliance rate with bedside barcode identification was 97.8%, and it was 99.5% in the past 6 months. The cause of failure of bedside barcode identification was human error in 811 cases (84.7%), handheld device error in 74 (7.7%), system error in 50 (5.2%) and wristband error in 23 (2.4%). The number of errors leading to failure of bedside barcode identification was decreased for human errors, especially manipulation errors, after initiation of notification at 1 h after issuing of blood. The transfusion service may have an important role in increasing transfusion safety by monitoring compliance with bedside verification and bedside use of issued blood.

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.

Safety in anaesthesia: a study of 12,606 reported incidents from the UK National Reporting and Learning System

The incident reporting database at the National Patient Safety Agency was interrogated on the nature, frequency and severity of incidents related to anaesthesia. Of 12,606 reports over a 2-year period, 2842 (22.5%) resulted in little harm or a moderate degree of harm, and 269 (2.1%) resulted in severe harm or death, with procedure or treatment problems generating the highest risk. One thousand and thirty-five incidents (8%) related to pre-operative assessment, with harm occurring in 275 (26.6%), and 552 (4.4%) related to epidural anaesthesia, with harm reported in 198 (35.9%). Fifty-eight occurrences of anaesthetic awareness were also examined. This preliminary analysis is not authoritative enough to warrant widespread changes of practice, but justifies future collaborative approaches to reduce the potential for harm and improve the submission, collection and analysis of incident reports. Practitioners, departments and professional bodies should consider how the information can be used to promote patient safety and their own defensibility.

Electronic remote blood issue: a combination of remote blood issue with a system for end-to-end electronic control of transfusion to provide a "total solution" for a safe and timely hospital blood transfusion service

BACKGROUND

The rapid provision of red cell (RBC) units to patients needing blood urgently is an issue of major importance in transfusion medicine. The development of electronic issue (sometimes termed "electronic crossmatch") has facilitated rapid provision of RBC units by avoidance of the serologic crossmatch in eligible patients. A further development is the issue of blood under electronic control at blood refrigerator remote from the blood bank.

STUDY DESIGN AND METHODS

This study evaluated a system for electronic remote blood issue (ERBI) developed as an enhancement of a system for end-to-end electronic control of hospital transfusion. Practice was evaluated before and after its introduction in cardiac surgery.

RESULTS

Before the implementation of ERBI, the median time to deliver urgently required RBC units to the patient was 24 minutes. After its implementation, RBC units were obtained from the nearby blood refrigerator in a median time of 59 seconds (range, 30 sec to 2 min). The study also found that unused requests were reduced significantly from 42 to 20 percent, the number of RBC units issued reduced by 52 percent, the number of issued units that were transfused increased from 40 to 62 percent, and there was a significant reduction in the workload of both blood bank and clinical staff.

CONCLUSIONS

This study evaluated a combination of remote blood issue with an end-to-end electronically controlled hospital transfusion process, ERBI. ERBI reduced the time to make blood available for surgical patients and improved the efficiency of hospital transfusion.

Red blood cell transfusion in clinical practice

Every year, about 75 million units of blood are collected worldwide. Red blood cell (RBC) transfusion is one of the few treatments that adequately restore tissue oxygenation when oxygen demand exceeds supply. Although the respiratory function of blood has been studied intensively, the trigger for RBC transfusion remains controversial, and doctors rely primarily on clinical experience. Laboratory assays that indicate failing tissue oxygenation would be ideal to guide the need for transfusion, but none has proved easy, reproducible, and sensitive to regional tissue hypoxia. The clinical importance of the RBCs storage lesion (ie, the time-dependent metabolic, biochemical, and molecular changes that stored blood cells undergo) is poorly understood. RBCs can be filtered, washed, frozen, or irradiated for specific indications. Donor screening and testing have dramatically reduced infectious risks in the developed world, but infection remains a major hazard in developing countries, where 13 million units of blood are not tested for HIV or hepatitis viruses. Pathogen inactivation techniques are in clinical trials for RBCs, but none is available for use. Despite serious immunological and non-immunological complications, RBC transfusion holds a therapeutic index that exceeds that of many common medications.