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

Towards Safe Patient Identification Practices: the Development of a Conceptual Framework from the Findings of a Ph.D. Project

Patient identification errors are considered the root cause of other patient safety incidents. Despite the development, recommendation, and application of several initiatives to reduce and prevent misidentification in hospital settings, errors continue to occur. They directly impact the quality of care provided, resulting in delays in care, added costs, unnecessary injuries, misdiagnosis or wrong treatment, and other serious and irreversible types of harm and death. Furthermore, the certainty of the evidence of the effectiveness of interventions to reduce patient identification errors is considered very low.

This paper reports on the development of a conceptual framework for safe practices in the area of patient identification. The proposed conceptual framework was developed based on presuppositions regarding learning health systems and the available evidence from the published systematic reviews of the effectiveness of interventions in reducing patient identification errors in hospital settings. The core circle of the framework represents the partnership between managers, healthcare professionals, patients, and families working toward integrative and collaborative efforts for safe patient identification practices. The inner dimension states the recommendations for practice sustained by applying technological resources and educational strategies to raise awareness of the importance of accurate patient identification and interdisciplinarity, which works as an axis that supports integrated and collective work between healthcare professionals aiming for safe care. The outer dimension represents recommendations for teaching and research to develop effective patient identification practices that can enhance patient safety and the quality of care provided in hospital settings.

This framework provides a valuable method for engaging interdisciplinary teams to improve the safety of patient identification systems.

Marques PA, Barker TH. Interventions to Reduce Patient Identification Errors in the Hospital Setting: A Systematic Review

Background:

Patient identification is considered as a fundamental part of the care process and a relevant resource for safety practices in hospital settings.

Objective:

We aimed to review the literature on interventions to reduce patient identification errors in hospital settings.

Methods:

A systematic review of effectiveness using The Joanna Briggs Institute (JBI) methodology was conducted. A three-step search strategy was utilised to explore primary research published up to March 2020 in English, Spanish, and Portuguese across eight databases. Grey literature was also assessed. The titles and abstracts of the studies were screened for assessment of the inclusion criteria. Two reviewers independently appraised the full text of the selected studies and extracted data using standardised tools from JBI. Due to the heterogeneity of studies and insufficient data for statistical pooling, meta-analysis was not feasible. Therefore, the results were synthesised narratively.

Results:

Twelve studies met the review criteria; all were rated at a moderate risk of bias and four different groups of interventions were identified: educational staff interventions alone and those combined with a partnership with families and patients through education; and information technology interventions alone, and combined with an educational staff strategy. Although most studies showed a statistically significant reduction in patient identification errors, the overall quality of the evidence was considered very low.

Conclusion:

High-quality research is needed to understand the real impact of interventions to reduce patient identification errors. Nurses should recognise the importance of patient identification practices as a part of their overall commitment to improving patient safety.

PROSPERO Registration Number: CRD42018085236

Evaluation of a two-sample process for prevention of ABO mistransfusions in a high volume academic hospital

Background

Acute haemolytic transfusion reactions due to ABO incompatible blood transfusion remain a leading cause of transfusion-associated morbidity and mortality in the USA. Erroneous patient identification and specimen labelling account for many errors that lead to ABO mistransfusions; these errors are largely preventable.

Methods

Our hospital requires a two-sample process of ABO/Rh typing prior to transfusion. Both samples must be drawn independently. To prevent simultaneous sample draw, our second sample tube has a unique pink top that is only available from the blood bank and can only be sent to the patient’s floor once the first sample arrives in the lab. We performed an audit of this process from 19 March to 30 July 2014 and 19 March to 30 July 2015.

Results

We reviewed type and crossmatch orders for 2702 new patients during the audit period and 824 patients (30.5%) required transfusion. All patients evaluated received compatible blood, and no mistransfusions were recorded using this method. Three per cent of testing was performed incorrectly, which safely defaulted to giving type O blood.

Conclusions

The two-sample protocol used by our institution can decrease the risk of mistransfusion. Our protocol was relatively inexpensive, safe, efficient and practical for adaptation by other hospitals.

Simulation as a toolkit-understanding the perils of blood transfusion in a complex health care environment

Background

Administration of blood is a complex process requiring vigilance and effective teamwork. Despite strict policies and training on blood administration, errors still occur and can lead to mistransfusion with adverse patient outcomes. We used an in situ simulated scenario within an operating room (OR) to identify weaknesses in the current process and hazards that could contribute to mistransfusion.

Methods

A process checklist of critical steps of safe transfusion was developed based on a large academic centre’s internal hospital policy and practice. Ten standardized operating room scenarios were conducted involving management of postoperative bleeding. Scenarios lasted 20 min or until blood transfusion was started. Debriefing followed immediately. Video recordings were reviewed, scored, and evaluated for team performance. Latent safety threats were identified. Focus groups further helped to identify rationale for decisions made. Participants completed questionnaires to evaluate the exercise.

Results

Forty-three experienced OR professionals participated. Of the 19 steps identified as essential for the safe administration of blood components, the median number of steps correctly completed per team was 11. The largest number of errors occurred when different team members interacted and during the immediate pre-transfusion check. We report that this type of learning immediately increased participants’ self-reported ability to perform in a team (90%) and to improve clinical care (88%).

Conclusions

In situ simulation is valuable in identifying common susceptibilities in blood administration error in a complex healthcare organization. Administrators and clinicians may wish to use simulation as an opportunity for system improvement in the delivery of quality care.

The Efficacy of Patients' Wristband Bar-code on Prevention of Medical Errors: A Meta-analysis Study

BACKGROUND

Patient misidentification, as a major patient safety issue, occurs in any healthcare setting and leads to inappropriate medical procedures, diagnosis or treatment, with serious outcomes.

OBJECTIVES

The study aimed to investigate the effectiveness of wristband bar-code medication scanning to reduce medical errors (ME).

METHODS

A meta-analysis study was conducted. The relevant studies were searched in PubMed, Embase, Cochrane Library, Web of Science and Scopus from 1990 to March 2015. Thereafter, the studies retrieved were screened based on predefined inclusion and exclusion criteria. Data were extracted, and the quality of the included studies was evaluated using the STROBE checklist.

RESULTS

In total, 14 articles involving 483 cases were included. The meta-analysis indicated that the use of wristband bar-code medication scanning can reduce the ME around 57.5% (OR=0.425, 95% CI: 0.28-0.65, P<0.001). The study results showed a marked heterogeneity in the subgroup analysis (I-squared=98%). This was I(2)=70.35, P-value=0.018 for the type of samples and I(2)=99%, P-value<0.001 for years and countries.

CONCLUSION

Wristband bar-code medication scanning can decrease the ME in hospital setting. Since the patient's safety is the main goal of the World Health Organization, it is recommended that a unique patient identification barcode should be used with name, medical record number, and bar-coded financial number.

Piloting the use of 2D barcode and patient safety-software in an Australian tertiary hospital setting

OBJECTIVES

Errors in administration of blood products can lead to poor patient outcomes including fatal ABO incompatible transfusions. This pilot study sought to establish whether the use of two-dimensional (2D) barcode technology combined with patient identification software designed to assist in blood administration improves the bedside administration of transfusions in an Australian tertiary hospital.

STUDY DESIGN AND METHODS

The study was conducted in a Haematology/Oncology Day Clinic of a major metropolitan hospital, to evaluate the use of 2D barcode technology and patient safety-software and hand-held PDAs to assist nursing staff in patient identification and blood administration. Comparative audits were conducted before and after the technology's implementation.

RESULTS

The preimplementation transfusion practice audits demonstrated a poor understanding of the blood checking process, with focus on the product rather than patient identification. Following the implementation of 2D barcode technology and patient safety-software, there was significant improvement in administration practice. Positive, verbal patient identification improved from 57% (51/90) to 94% (75/80). Similarly, the cross-referencing of the patient's identification with the patient's wristband improved from 36% (32/90) to 94% (75/80), and the cross-referencing of patient ID on the compatibility tag to wristbands improved from 48% (43/90) to 99% (79/80). Importantly, the 2D barcode technology and patient safety-software saw 100% (80/80) of checks being conducted at the patient bedside, compared with 76% (68/90) in the preimplementation audits.

CONCLUSION

This pilot study demonstrates that 2D barcode technology and patient safety-software significantly improves the bedside check of patient and blood product identification in an Australian setting.

Reduction in pediatric identification band errors: a quality collaborative

BACKGROUND AND OBJECTIVE

Accurate and consistent placement of a patient identification (ID) band is used in health care to reduce errors associated with patient misidentification. Multiple safety organizations have devoted time and energy to improving patient ID, but no multicenter improvement collaboratives have shown scalability of previously successful interventions. We hoped to reduce by half the pediatric patient ID band error rate, defined as absent, illegible, or inaccurate ID band, across a quality improvement learning collaborative of hospitals in 1 year.

METHODS

On the basis of a previously successful single-site intervention, we conducted a self-selected 6-site collaborative to reduce ID band errors in heterogeneous pediatric hospital settings. The collaborative had 3 phases: preparatory work and employee survey of current practice and barriers, data collection (ID band failure rate), and intervention driven by data and collaborative learning to accelerate change.

RESULTS

The collaborative audited 11377 patients for ID band errors between September 2009 and September 2010. The ID band failure rate decreased from 17% to 4.1% (77% relative reduction). Interventions including education of frontline staff regarding correct ID bands as a safety strategy; a change to softer ID bands, including "luggage tag" type ID bands for some patients; and partnering with families and patients through education were applied at all institutions.

CONCLUSIONS

Over 13 months, a collaborative of pediatric institutions significantly reduced the ID band failure rate. This quality improvement learning collaborative demonstrates that safety improvements tested in a single institution can be disseminated to improve quality of care across large populations of children.

Patient involvement in blood transfusion safety: patients' and healthcare professionals' perspective

BACKGROUND

Blood transfusion is one of the major areas where serious clinical consequences, even death, related to patient misidentification can occur. In the UK, healthcare professional compliance with pre-transfusion checking procedures which help to prevent misidentification errors is poor. Involving patients at a number of stages in the transfusion pathway could help prevent the occurrence of these incidents.

OBJECTIVES

To investigate patients' willingness to be involved and healthcare professionals' willingness to support patient involvement in pre-transfusion checking behaviours.

MEASURES

A cross-sectional design was employed assessing willingness to participate in pre-transfusion checking behaviours (patient survey) and willingness to support patient involvement (healthcare professional survey) on a scale of 1-7.

PARTICIPANTS

One hundred and ten patients who had received a transfusion aged between 18 and 93 (60 male) and 123 healthcare professionals (doctors, nurses and midwives) involved in giving blood transfusions to patients.

RESULTS

Mean scores for patients' willingness to participate in safety-relevant transfusion behaviours and healthcare professionals' willingness to support patient involvement ranged from 4.96-6.27 to 4.53-6.66, respectively. Both groups perceived it most acceptable for patients to help prevent errors or omissions relating to their hospital identification wristband. Neither prior experience of receiving a blood transfusion nor professional role of healthcare staff had an effect on attitudes towards patient participation.

CONCLUSION

Overall, both patients and healthcare professionals view patient involvement in transfusion-related behaviours quite favourably and appear in agreement regarding the behaviours patients should adopt an active role in. Further work is needed to determine the effectiveness of this approach to improve transfusion safety.

He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices

BACKGROUND

Accurate patient identification (PT ID) is a key component in hospital patient safety practices and was addressed by one of the first six Joint Commission National Patient Safety Goals, which were introduced in 2003. Although the literature on patient safety practices is replete with discussion of strategies for improvement, less is known about frontline providers' subjective views. A qualitative study was conducted to examine the subjective views and experiences of nurses and residents regarding PT ID at an urban teaching hospital.

METHODS

Some 15 registered nurses and 15 residents were interviewed between August 2009 and June 2010. Transcripts were analyzed using qualitative methodologies.

FINDINGS

Although residents and nurses viewed PT ID as crucial to patient safety, they cited time pressures; confidence in their ability to informally identify patients; and a desire to deliver personal, humanistic care as reasons for not consistently verifying patient identification. Nurses expressed concern about annoying, offending, and/or alienating patients by repeatedly checking wristbands and asking date of birth, in the belief that excessive patient identification practices could undermine trust. Residents relied on nurses to check ID and preferred to greet the patient by name, a practice that they viewed as more consistent with their professional identity. Referring to patients by their room number and location was cited as a commonly used practice of PT ID and a contributor to errors in identification.

CONCLUSIONS

Nurses and residents are aware of the importance and requirements to verify PT ID, but their adherence is mitigated by a variety of factors, including assessment of necessity or risk, impact on their relationship with the patient, and practices in place in the hospital environment that protect patient privacy.

Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST)

BACKGROUND

One of the most frequent causes of transfusion-associated morbidity or mortality is the transfusion of the wrong blood to the wrong patient. This problem persists in spite of the incorporation of numerous procedures into the pretransfusion checking process in an effort to improve patient safety. A qualitative study was undertaken to understand this process from the perspective of those who administer blood products and to identify concerns and suggestions to improve safety.

STUDY DESIGN AND METHODS

Twelve focus group discussions and seven individual interviews were conducted at six hospitals in five countries (n = 72 individuals). Health care professionals from a variety of clinical areas participated. Data analysis identified common themes using the constant comparison method.

RESULTS

Five major themes emerged from the analysis: the pretransfusion checking process, training, policy, error, and monitoring. Findings include the following: staff were aware and appreciative of the seriousness of errors and were receptive to continuous monitoring, the focus was on checking the bag label with the paperwork rather than the bag label with the patient at the bedside, training methods varied with most perceived to have minimal effectiveness, and access to policies was challenging and keeping up to date was difficult. Other factors that could contribute to errors included high volume of workload distractions and interruptions and familiarity or lack of familiarity with patients.

CONCLUSIONS

Multiple factors can contribute to errors during the pretransfusion checking limiting the effectiveness of any individual intervention designed to improve safety. Areas of further research to improve safety of blood administration were identified.

Managing transfusion service quality

CONTEXT

Providing blood products for transfusions is a complex process subject to errors both within and outside the transfusion service. Transfusion-related errors can have grave consequences for the patient undergoing transfusion. As with many processes performed within health care systems, there is an expectation of error-free practice. Although this is an unobtainable goal, a focused quality-management plan, employing a medical event reporting system in a just working environment, can effect measurable system-quality improvement.

OBJECTIVE

To illustrate the intrinsic value of quality-improvement activities through discussion of examples of quality misadventures from our transfusion service during the past 20 years.

DATA SOURCES

Examples of quality-improvement activities were extracted from our quality-system archives. The published literature on transfusion quality was reviewed.

CONCLUSIONS

Active reporting, structured investigation, and systematic resolution of transfusion-related errors are effective methods for improving and maintaining transfusion quality.

Improved traceability and transfusion safety with a new portable computerised system in a hospital with intermediate transfusion activity

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.

Checking in healthcare safety: theoretical basis and practical application

PURPOSE

Healthcare includes important processes such as checking to reduce errors. Checking is a prescribed part of many patient care activities with many checks being performed during one hospital admission. Some may be standard but unwritten practices, whereas others are laid down in official guidance. Errors in the bedside checking procedure are the commonest cause of mis-transfusion, so more thorough checking could prevent adverse events. This paper aims to explore and enhance understanding regarding healthcare checking procedures. In doing so it seeks to identify a further research agenda.

DESIGN/METHODOLOGY/APPROACH

The computerised databases CINAHL, PsycLIT, EMBASE, PubMed, PsycINFO and MEDLINE were searched using specific indexing terms and free text including "bedside, peri-operative safety, theatre checking and checklists". Only English publications were included.

FINDINGS

Like any human activity, checking is part of personality and behaviour. There are several psychological factors relevant to patient safety, including: memory, prospective memory, automaticity and responsibility. All are relevant to healthcare.

RESEARCH LIMITATIONS/IMPLICATIONS

Bandolier criteria have not explicitly been used within this review but have been met. It would be beneficial for future reviews to explicitly state how Bandolier criteria are met. This would possibly enhance the publications' scientific quality.

PRACTICAL IMPLICATIONS

There is much to learn regarding interacting factors that influence healthcare checking procedures and ultimately checking performance. The authors recommend that relationships between checking and personality should be explored. Furthermore, exploring how healthcare "mindfulness" might be promoted and what reminder/checking strategies healthcare staff already use in their day-to-day work routines should be examined.

ORIGINALITY/VALUE

Several psychological factors involved in checking and its relevance to healthcare and patient safety are identified. Additionally, recommendations for further research are indicated.

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.

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

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