Application of bar code technology at the bedside: the Oxford experience

Improving Transfusion Safety in the Operating Room With a Barcode Scanning System Designed Specifically for the Surgical Environment and Existing Electronic Medical Record Systems: An Interrupted Time Series Analysis

BACKGROUND

Manual processes for verifying patient identification before blood transfusion and documenting this pretransfusion safety check are prone to errors, and compliance with manual systems is especially poor in urgent operating room settings. An automated, electronic barcode scanner system would be expected to improve pretransfusion verification and documentation.

METHODS

Audits were conducted of blood transfusion documentation under a manual paper system from January to October 2014. An electronic barcode scanning system was developed to streamline transfusion safety checking and automate documentation. This system was implemented in 58 operating rooms between October and December 2014, with follow-up compliance audits through December 2015. The association of barcode scanner implementation with transfusion documentation compliance was assessed using an interrupted time series analysis. Anesthesia providers were surveyed regarding their opinions on the electronic system. In mid-2016, the scanning system was modified to transfer from the Metavision medical record system to Epic OpTime. Follow-up analysis assessed performance of this system within Epic during 2017.

RESULTS

In an interrupted time series analysis, the proportion of units with compliant documentation was estimated to be 19.6% (95% confidence interval [CI], 10.7-25.6) the week before scanner implementation, and 74.4% (95% CI, 59.4-87.4) the week after implementation. There was a significant postintervention level change (odds ratio 10.80, 95% CI, 6.31-18.70; P < .001) and increase in slope (odds ratio 1.14 per 1-week increase, 95% CI, 1.11-1.17; P < .001). After implementation, providers chose to use the new electronic system for 98% of transfusions. Across the 2 years analyzed (15,997 transfusions), the electronic system detected 45 potential transfusion errors in 27 unique patients, and averted transfusion of 36 mismatched blood products into 20 unique patients. A total of 69%, 86%, and 88% of providers reported the electronic system improved patient safety, blood transfusion workflow, and transfusion documentation, respectively. When providers used the barcode scanner, no transfusion errors or reactions were reported. The scanner system was successfully transferred from Metavision to Epic without retraining staff or changing workflows.

CONCLUSIONS

A barcode-based system designed for easy integration to different commonly used anesthesia information management systems was implemented in a large urban academic hospital. The system allows a single user with the assistance of a software system to perform and document pretransfusion safety verification. The system improved transfusion documentation compliance, averted potential transfusion errors, and became the preferred method of blood transfusion safety checking.

Implementation and Effectiveness of a Bar Code-Based Transfusion Management System for Transfusion Safety in a Tertiary Hospital: Retrospective Quality Improvement Study

Background

Large-scale and long-term studies are not sufficient to determine the efficiency that IT solutions can bring to transfusion safety.

Objective

This quality-improvement report describes our continuous efforts to implement and upgrade a bar code–based transfusion management (BCTM) system since 2011 and examines its effectiveness and sustainability in reducing blood transfusion errors, in a 3000-bed tertiary hospital, where more than 60,000 prescriptions of blood transfusion are covered by 2500 nurses each year.

Methods

The BCTM system uses barcodes for patient identification, onsite labeling, and blood product verification, through wireless connection to the hospital information systems. Plan-Do-Study-Act (PDSA) cycles were used to improve the process. Process maps before and after implementation of the BCTM system in 2011 were drawn to highlight the changes. The numbers of incorrect labeling or wrong blood in tube incidents that occurred quarterly were plotted on a run chart to monitor the quality changes of each intervention introduced. The annual occurrences of error events from 2011 to 2017 were compared with the mean occurrence of 2008-2010 to determine whether implementation of the BCTM system could effectively reduce the number of errors in 2016 and whether this reduction could persist in 2017.

Results

The error rate decreased from 0.03% in 2008-2010 to 0.002% in 2016 (P<.001) and 0.001% in 2017 (P<.001) after implementation of the BTCM system. Only one incorrect labeling incident was noted among the 68,324 samples for blood typing, and no incorrect transfusions occurred among 67,423 transfusion orders in 2017.

Conclusions

This report demonstrates that continuous efforts to upgrade the existing process is critical to reduce errors in transfusion therapy, with support from information technology.

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

BACKGROUND

Compared to blood component safety, the administration of blood may not be as safe as intended. The German Interdisciplinary Task Force for Clinical Hemotherapy (IAKH) specialized registry for administration errors of blood products was chosen for a detailed analysis of reports.

METHODS

Voluntarily submitted critical incident reports (n = 138) from 2009 to 2013 were analyzed.

RESULTS

Incidents occurred in the operation room (34.1%), in the ICU (25.2%), and in the peripheral ward (18.5%). Procedural steps with errors were administration to the patient (27.2%), indication and blood order (17.1%), patient identification (17.1%), and blood sample withdrawal and tube labeling (18.0%). Bedside testing (BST) of blood groups avoided errors in only 2.6%. Associated factors were routine work conditions (66%), communication error (36%), emergency case (26%), night or weekend team (39%), untrained personnel (19%). Recommendations addressed process and quality (n = 479) as well as structure quality (n = 314). In 189 instances, an IT solution would have helped to avoid the error.

CONCLUSIONS

The administration process is prone to errors at the patient assessment for the need to transfuse and the application of blood products to patients. BST is only detecting a minority of handling errors. According to the expert recommendations for practice improvement, the potential to improve transfusion safety by a technical solution is considerable.

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.

[Evaluation of the launch of an unambiguous patient identification strategy in the hospitals of the Valencian Healthcare Agency (Spain)]

INTRODUCTION AND OBJECTIVE

Identification problems are associated with errors arising in the course of providing patient care. To improve patient safety, a universal and unambiguous identification system is required. The aim of this study was to assess the experience of designing, implementing and evaluating the launch of a strategy for unambiguous patient identification, using an identification bracelet in all the hospitals of the Valencian Healthcare Agency.

METHOD

The assessment included the design of the identification material (bracelet) and its contents; the production, placement and identification of the bracelets, and the degree of implementation achieved at the launch of this strategy.

RESULTS

The identification strategy was successfully implemented in a satisfactory proportion of sites (100% of the hospitals and 76% of hospital emergency departments within the first 24 hours of its functioning). Evaluation of the points defined as critical also showed high levels of compliance. Overall, the experience described could help the deployment of similar efforts in other centers and health services.

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.