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Staves J, Ashford P, Bullock T, Coates T, Lodge L, Patel N, Rowley M, Sargant N, George CE. Guidelines for the specification, implementation and management of IT systems in hospital transfusion laboratories: A British Society for Haematology Guideline. Transfus Med 2024; 34:83-111. [PMID: 38265158 DOI: 10.1111/tme.13027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/27/2023] [Accepted: 12/12/2023] [Indexed: 01/25/2024]
Affiliation(s)
- Julie Staves
- Transfusion Laboratory, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul Ashford
- IT consultant, Roper Management Consultants Ltd, Kent, UK
| | - Tom Bullock
- Red Cell Immunohaematology, NHS Blood and Transplant, Bristol, England
| | - Tony Coates
- Transfusion Laboratory, Betsi Cadwaladr University Health Board, Wales, UK
| | - Linda Lodge
- Clinical Services, Scottish National Blood Transfusion Service, Edinburgh, Scotland
| | - Nishil Patel
- Haematology, Royal Free London NHS Foundation Trust, Barnet, UK
| | - Megan Rowley
- Clinical Services, Scottish National Blood Transfusion Service, Edinburgh, Scotland
| | - Nigel Sargant
- Haematology, East Sussex Healthcare NHS Trust, East Sussex, UK
| | - Chloë E George
- Clinical Services, Welsh Blood Service, Velindre NHS Trust, Cardiff, UK
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2
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Davies J, Tuckley V, McGrann A, Rowley M, Clarke H, Baker P, Narayan S. SHOT UK Collaborative Reviewing and Reforming IT Processes in Transfusion (SCRIPT) survey: Laboratory information management systems: Are we ready for digital transformation? Transfus Med 2023; 33:433-439. [PMID: 37776051 DOI: 10.1111/tme.13010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/07/2023] [Accepted: 09/09/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVES To understand the use, functionality and interoperability of laboratory information management systems (LIMS) in UK transfusion laboratories. BACKGROUND LIMS are widely used to support safe transfusion practice. LIMS have the potential to reduce the risk of laboratory error using algorithms, flags and alerts that support compliance with best practice guidelines and regulatory standards. Reporting to Serious Hazards of Transfusion (SHOT), the United Kingdom (UK) haemovigilance scheme, has identified cases where the LIMS could have prevented errors but did not. Shared care of patients across different organisations and the development of pathology networks has raised challenges relating to interoperability of IT systems both within, and between, organisations. METHODS AND MATERIALS A survey was distributed to all SHOT-reporting organisations to understand the current state of LIMS in the UK, prevalence of expertise in transfusion IT, and barriers to progress. Survey questions covered LIMS interoperability with other IT systems used in the healthcare setting. RESULTS A variety of LIMS and version numbers are in use in transfusion laboratories, LIMS are not always updated due to resource constraints. Respondents identified interoperability and improved functionality as the main requirements for transfusion safety. CONCLUSION A nationally agreed set of minimum standards for transfusion LIMS is required for safe practice. Adequate resources, training and expertise should be provided to support the effective use and timely updates of LIMS. A single LIMS solution should be in place for transfusion laboratories working within a network and interoperability with other systems should be explored to further improve practice.
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Affiliation(s)
- Jennifer Davies
- Transfusion Department, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | | | - Alistair McGrann
- Haematology Department, Northampton General Hospital NHS Trust, Northampton, UK
| | - Megan Rowley
- Transfusion Department, Scottish National Blood Transfusion Service, Scotland, UK
| | - Heather Clarke
- Transfusion Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Peter Baker
- Transfusion Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Shruthi Narayan
- Haemovigilance, Serious Hazards of Transfusion, Manchester, UK
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3
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Toh CH. How can we ensure that the right patient gets the right blood at the right time? BMJ 2023; 383:2446. [PMID: 37871957 DOI: 10.1136/bmj.p2446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
- Cheng-Hock Toh
- University of Liverpool and Liverpool University Hospitals NHS Foundation Trust, UK
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4
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Xu GP, Wu LF, Xu XM, Li JJ, Gao Q, Lu H. Information technology improves the quality of transfusion practice in China. Vox Sang 2023; 118:138-146. [PMID: 36534000 DOI: 10.1111/vox.13393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Transfusion services in China must establish a quality management system, and regular inspection of quality indicators is an important component of quality management. Although the positive role of information technology in reducing human errors has been widely reported, its role in improving transfusion quality indicators still requires further study. This study explores the role of information technology in improving the quality of transfusion practice. MATERIALS AND METHODS We developed an optimized blood transfusion management information system and then analysed the changes in four quality indicators before and after using the system to clarify the role of information technology in improving the quality of transfusion practice. RESULTS After using the optimized system, the completeness rate for transfusion request forms increased from 81.5% to 99.3%; an unqualified doctor's signature was the most common incomplete content (0.45%). The appropriate transfusion rate increased from 87% to 99.4%, and red blood cell and frozen plasma utilization in most surgical departments decreased. Although the reporting rate for adverse transfusion reactions increased from 0.22% to 0.49%, these increases might be partly due to changes in transfusion regulations. The adequacy rate of transfusion medical records increased from 74.8% to 90.4%. Overall, the inadequacy of informed consent for transfusion, pre-transfusion laboratory tests and documentation of the transfusion process were reduced from 6.4%, 6.2% and 12.6% to 1.7%, 2.0% and 5.9%, respectively. CONCLUSION Information technology can play an important role in improving the quality of transfusion practice, as part of a programme of medical education, regular audit and other measures.
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Affiliation(s)
- Gui-Ping Xu
- Transfusion Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li-Fang Wu
- Department of Laboratory Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Min Xu
- Transfusion Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing-Jing Li
- Transfusion Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Gao
- Transfusion Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hua Lu
- Transfusion Department, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Uramatsu M, Maeda H, Mishima S, Takahashi M, Wada J, Amano K, Barach P, Miki T. Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. J Cardiothorac Surg 2022; 17:182. [PMID: 35974374 PMCID: PMC9382733 DOI: 10.1186/s13019-022-01931-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The past half century has seen the near eradication of transfusion-associated hazards. Intraoperative cell salvage while widely used still poses significant risks and hazards due to human error. We report on a case in which blood collected from a patient with lung cancer was mistakenly administered to a patient undergoing cardiac surgery who should have received his own collected blood. The initial investigation found that the cause of the patient harm was violations of procedures by hospital personnel. A detailed investigation revealed that not only violations were the cause, but also that the underlying causes included haphazard organizational policies, poor communication, workload and staffing deficiencies, human factors and cultural challenges. CASE PRESENTATION On August 14, 2019, a 72-year-old male was admitted to our hospital for angina pectoris and multivessel coronary artery disease. Cardiac surgery was performed using an autologous salvage blood collection system, and there were no major problems other than the prolonged operation time. During the night after the surgery, when the patient's blood pressure dropped, a nurse retrieved a blood bag from the ICU refrigerator that had been collected during the surgery and administered it at the physician's direction, but at this time neither the physician nor the nurse performed the required checking procedures. The blood administered was another patient's blood taken from another surgery the day before; an ABO mismatch transfusion occurred and the patient was diagnosed with DIC. The patient was discharged 65 days later after numerous interventions to support the patient. An accident investigation committee was convened to analyze the root causes and develop countermeasures to prevent a recurrence. CONCLUSION This adverse event occurred because the protocol for intraoperative blood salvage management was not clearly defined, and the procedure was different from the standard transfusion practices. We developed a new workflow based on a human factors grounded, systems-wide improvement strategy in which intraoperative blood collection would be administered before the patient leaves the operating room to completely prevent recurrence, instead of simply requiring front-line staff to do a double-check. Implementing strong systems processes can reduce the risk of errors, improve the reliability of the work processes and reduce the likelihood of patient harm occurring in the future.
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Affiliation(s)
- Masashi Uramatsu
- Department of Quality and Patient Safety, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan. .,Section of Medical Safety Management, Tokyo Medical University Hospital, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Hideyuki Maeda
- Department of Forensic Medicine, Graduate School of Medicine, Tokyo Medical University, 1-1-1 Shinjuku, Shinjuku-ku, Tokyo, 160-8402, Japan
| | - Shiro Mishima
- Department of Quality and Patient Safety, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.,Section of Medical Safety Management, Tokyo Medical University Hospital, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Megumi Takahashi
- Department of Quality and Patient Safety, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.,Section of Medical Safety Management, Tokyo Medical University Hospital, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Jun Wada
- Department of Quality and Patient Safety, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.,Section of Medical Safety Management, Tokyo Medical University Hospital, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University Hospital, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Paul Barach
- Thomas Jefferson University School of Medicine, Philadelphia, PA, USA.,University of Queensland School of Medicine, Brisbane, Australia.,Medical University of Graz, Graz, Austria
| | - Tamotsu Miki
- Department of Quality and Patient Safety, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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6
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Shin KH, Lee HJ, Oh SH, Jo SY, Lee SM, Kim IS. Sample collection for pre-transfusion crossmatching: Benefits of using an electronic identification system. Transfus Med 2022; 32:299-305. [PMID: 35365920 DOI: 10.1111/tme.12863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/10/2022] [Accepted: 03/08/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Transfusion of ABO blood group-mismatched blood or administration to the wrong recipient may result in fatal adverse events. To prevent these types of errors, various strategies have been employed. Recently, we developed a novel sample collection workflow for the pre-transfusion crossmatching test and patient recognition. This study aimed to analyse the usage of the new workflow and improvements in outcomes. METHODS We analysed the number of crossmatching and wrong-patient errors among the blood transfusion cases during 3 years of data collection (from August 2018 to July 2021). From May 2021 to July 2021, the new workflow was implemented. Outcomes were calculated according to the department type, patient age and processing time. The sample processing time was defined as the time from placing the order to lab arrival. RESULTS The new workflow utilisation increased from 50.7% to 80.3% and wrong-patient errors decreased annually. The new workflow was used for more adults (3001/3680 samples, 81.5%) than paediatric cases (345/522 samples, 65.5%; p < 0.001) and in general wards than in the emergency room or intensive care unit. The sample processing time differed according to ward type and timing of the request (day: 28.80, 2.43-3889.43 min, night: 3.36, 2.72-1671.47 min; p < 0.001). CONCLUSION Wrong-patient errors were reduced without increasing sample-processing time after introducing the new workflow which included using an electronic identification system. The time needed for the blood processing differed according to the ward type, patient age, and timing of the request. Patient safety can be promoted by managing these factors and using an electronic identification system.
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Affiliation(s)
- Kyung-Hwa Shin
- Department of Laboratory Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Hyun Ji Lee
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Seung-Hwan Oh
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Su-Yeon Jo
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Sun Min Lee
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - In-Suk Kim
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
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7
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Passwater M, Huggins YM, Delvo Favre ED, Mukhtar F, Pelletier JPR. Adding Automation and Independent Dual Verification to Reduce Wrong Blood in Tube (WBIT) Events. Am J Clin Pathol 2022; 158:212-215. [PMID: 35304892 DOI: 10.1093/ajcp/aqac031] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Transfusions remain a complicated procedure involving many disciplines performing various steps. Pretransfusion specimen identification errors remain a concern. Over the past two decades, system changes have been made and minimal improvements in the error rates have been seen. Wrong blood in tube (WBIT) events may lead to mistransfusions of components with life-threatening complications. METHODS A continuous quality improvement effort involving the introduction of electronic patient identification at the point of pretransfusion specimen collection (an automated system improvement), manual independent dual verification, and periodic education (human process system improvements) were implemented. RESULTS Both automated and human system process improvements resulted in greater than 10-fold reduction in WBIT events and a 47% reduction in mislabeled specimens. CONCLUSIONS Diligent improvement and implementation of combination automated system processes and human protocols with continuous monitoring led to great reductions in WBIT error rates and labeling discrepancies, leading to an increase in system safety. These combinations of improvement can lead to more decreased error rates if applied to other critical process steps in the transfusion process.
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Affiliation(s)
| | | | | | - Faisal Mukhtar
- UF Health Shands Hospital, Gainesville, FL, USA
- Department of Pathology, Immunology, Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - J Peter R Pelletier
- UF Health Shands Hospital, Gainesville, FL, USA
- Department of Pathology, Immunology, Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
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Crispin P, Akers C, Brown K, Delaforce A, Keegan A, King F, Ormerod A, Verrall T. A review of electronic medical records and safe transfusion practice for guideline development. Vox Sang 2022; 117:761-768. [PMID: 35089600 DOI: 10.1111/vox.13254] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/22/2021] [Accepted: 11/26/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Philip Crispin
- Clinical Practice Improvement Committee of Australian and New Zealand Society of Blood Transfusion, Sydney, NSW, Australia.,Department of Haematology, Canberra Hospital, Garran, ACT, Australia.,Australian National University Medical School, Acton, ACT, Australia
| | - Christine Akers
- Clinical Practice Improvement Committee of Australian and New Zealand Society of Blood Transfusion, Sydney, NSW, Australia.,Victorian Department of Health and Human Services, Blood Matters Program, Melbourne, Victoria, Australia
| | - Kristen Brown
- Clinical Practice Improvement Committee of Australian and New Zealand Society of Blood Transfusion, Sydney, NSW, Australia.,Medical Services, Murrumbidgee Area Health Service, Wagga Wagga, NSW, Australia
| | - Alana Delaforce
- Clinical Practice Improvement Committee of Australian and New Zealand Society of Blood Transfusion, Sydney, NSW, Australia.,Mater Health Services, South Brisbane, QLD, Australia.,Mater Research Institute-UQ, South Brisbane, QLD, Australia.,School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW, Australia
| | - Anastazia Keegan
- Clinical Practice Improvement Committee of Australian and New Zealand Society of Blood Transfusion, Sydney, NSW, Australia.,Transfusion Policy and Education, Australian Red Cross Lifeblood, Perth, Western Australia, Australia.,Department of Haematology, Nepean Hospital, New South Wales, Australia
| | - Fiona King
- Clinical Practice Improvement Committee of Australian and New Zealand Society of Blood Transfusion, Sydney, NSW, Australia.,New Zealand Blood Service, Wellington, New Zealand
| | - Amanda Ormerod
- Clinical Practice Improvement Committee of Australian and New Zealand Society of Blood Transfusion, Sydney, NSW, Australia.,Department of Haematology, Latrobe Regional Health, Traralgon, Victoria, Australia
| | - Trudi Verrall
- Clinical Practice Improvement Committee of Australian and New Zealand Society of Blood Transfusion, Sydney, NSW, Australia.,BloodSafe eLearning, Adelaide, South Australia, Australia
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O' Herlihy N, Griffin S, Gaffney R, Henn P, Khashan AS, Ring M, Gallagher A, Cahill MR. Proficiency-based progression intern training to reduce critical blood sampling errors including ‘wrong blood in tube’. HRB Open Res 2021. [DOI: 10.12688/hrbopenres.13329.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Blood sampling errors including ‘wrong blood in tube’ (WBIT) may have adverse effects on clinical outcomes. WBIT errors occur when the blood sample in the tube is not that of the patient identified on the label. This study aims to determine the effect of proficiency-based progression (PBP) training in phlebotomy on the rate of blood sampling errors (including WBIT). Methods: A non-randomised controlled trial compared the blood sampling error rate of 43 historical controls who had not undergone PBP training in 2016 to 44 PBP trained interventional groups in 2017. In 2018, the PBP training programme was implemented and the blood sampling error rate of 46 interns was compared to the 43 historical controls in 2016. Data analysis was performed using logistic regression analysis adjusting for sample timing. Results: In 2016, 43 interns had a total blood sample error rate of 2.4%, compared to 44 interns in 2017, who had error rate of 1.2% (adjusted OR=0.50, 95% CI 0.36-0.70; <0.01). In 2018, 46 interns had an error rate of 1.9% (adjusted OR=0.89, 95% CI 0.65-1.21; p=0.46) when compared to the 2016 historical controls. There were three WBITs in 2016, three WBITs in 2017 and five WBITs in 2018. Conclusions: The study demonstrates that PBP training in phlebotomy has the potential to reduce blood sampling errors. Trial registration number: NCT03577561
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10
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Dunbar NM, Kaufman RM. Factors associated with wrong blood in tube errors: An international case series - The BEST collaborative study. Transfusion 2021; 62:44-50. [PMID: 34726274 DOI: 10.1111/trf.16716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/03/2021] [Accepted: 10/11/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND A wrong blood in tube (WBIT) error signifies a blood sample that does not match the patient identified on the sample label. WBIT errors can result in ABO mistransfusions. STUDY DESIGN AND METHODS In this international, multicenter, descriptive study, healthcare facilities provided detailed information on WBIT errors occurring from 1/1/2019 to 12/31/2020. Factors contributing to WBIT errors were classified as protocol violations, knowledge gaps, and slips/lapses. RESULTS 331 WBIT errors were compiled from 36 centers in 11 countries. WBIT errors were most frequently detected through pretransfusion sample testing (191, 58%), with 38 (20%) detected by a second ("check") sample. WBIT errors were divided almost evenly between intended patient drawn/wrong label applied (166, 50%) and wrong patient drawn/intended label applied (158, 48%). Information on contributing factors was available for 260 WBIT errors; most involved a combination of protocol violations and slips/lapses (139, 53%). The most frequent contributing factor was another patient's sample labels or tubes being available during phlebotomy (61%). Protocol violations were more likely to result in wrong patient being drawn (p = .0007). In 43 WBIT errors, electronic positive patient identification (ePPID) was not used when available or was used incorrectly. CONCLUSIONS Protocol violations and slips/lapses frequently contribute to WBIT errors. Sample collection processes should be designed to minimize error opportunities; staff should be educated on why protocol compliance is critical for patient safety. Using ePPID does not eliminate all WBIT errors. Institutions using ePPID may elect to require check sample verification as an added safety measure.
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Affiliation(s)
- Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Richard M Kaufman
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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11
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Allard S, Cort J, Howell C, Sherliker L, Miflin G, Toh CH. Transfusion 2024: A 5-year plan for clinical and laboratory transfusion in England. Transfus Med 2021; 31:400-408. [PMID: 34693582 DOI: 10.1111/tme.12827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/30/2021] [Accepted: 10/10/2021] [Indexed: 01/28/2023]
Abstract
The Transfusion 2024 plan outlines key priorities for clinical and laboratory transfusion practice for safe patient care across the NHS for the next 5 years. It is based on the outcomes of a multi-professional symposium held in March 2019, organised by the National Blood Transfusion Committee (NBTC) and NHS Blood and Transplant (NHSBT), attended and supported by Professor Keith Willet and Dame Sue Hill on behalf of NHS England and Improvement. This best practice guidance contained within this publication will facilitate the necessary change in pathway design to meet the transfusion challenges and pressures for the restoration of a cohesive, and functional, healthcare system across the NHS following the COVID-19 pandemic.
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Affiliation(s)
- Shubha Allard
- Department of Medical, NHS Blood and Transplant, London, UK
| | - Jon Cort
- Department of Clinical, Chesterfield Royal Hospital NHS Foundation Trust, Derbyshire, UK
| | | | | | - Gail Miflin
- Department of Medical, NHS Blood and Transplant, Cambridge, UK
| | - Cheng Hock Toh
- Department of Clinical, University of Liverpool on behalf of NHSBT and NBTC, Liverpool, UK
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12
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Murphy MF. Hemovigilance drives improved transfusion safety. Transfusion 2021; 61:1333-1335. [PMID: 33831223 DOI: 10.1111/trf.16322] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Michael F Murphy
- NHS Blood & Transplant, Oxford, UK.,National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals and the University of Oxford, Oxford, UK
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13
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Dunbar NM, Delaney M, Murphy MF, Pagano MB, Saifee NH, Seheult J, Yazer M, Kaufman RM. Emergency departments are higher-risk locations for wrong blood in tube errors. Transfusion 2021; 61:2601-2610. [PMID: 34268775 DOI: 10.1111/trf.16588] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/10/2021] [Accepted: 06/12/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Wrong blood in tube (WBIT) errors can lead to ABO mistransfusions. It is unknown if WBIT errors are more likely in specific healthcare locations or if specific collection practices influence the commission of WBIT errors. STUDY DESIGN AND METHODS Data on pretransfusion samples from calendar year 2019 were collected retrospectively by 39 transfusion services in nine countries. We compared the proportion of WBIT errors made in emergency departments (EDs), inpatient wards, and outpatient clinics. RESULTS In total, 143 WBIT errors were detected among 1,394,862 samples for an unadjusted aggregate WBIT proportion of 1.03/10,000 samples. Using a pooled random effects model, the WBIT proportion was estimated to be significantly higher in EDs (1.23/10,000 samples, 95% CI 0.62-2.43) than inpatient wards (0.71/10,000, 95% CI 0.44-1.14; p < .001) or outpatient clinics (0.24/10,000, 95% CI 0.08-0.65; p < .001) and significantly higher in inpatient wards than outpatient clinics (p = .043). The use of electronic positive patient identification (ePPID) systems was associated with a significantly lower WBIT proportion in the ED (odds ratio, OR: 0.32, 95% CI: 0.11-0.96, p = .041), but not in inpatient wards (OR: 0.45, 95% CI: 0.20-1.01, p = .054) or outpatient clinics (OR: 1.95, 95% CI: 0.39-9.74, p = .415). DISCUSSION Normalized for the number of samples drawn per location, the WBIT proportion in EDs was 1.7 times higher than inpatient wards and 5.1 times higher than outpatient clinics. EDs represent higher-risk clinical locations for WBIT errors, and electronic positive patient identification (ePPID) may provide a greater impact on safety in EDs relative to other clinical areas.
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Affiliation(s)
- Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Meghan Delaney
- Division Pathology & Laboratory Medicine, Children's National Hospital and Department of Pathology and Pediatrics, The George Washington University, Washington, District of Columbia, USA
| | - Michael F Murphy
- NHS Blood & Transplant, and Oxford Biomedical Research Centre, Oxford, UK
| | - Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Nabiha Huq Saifee
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA.,Bloodworks Northwest, Seattle, Washington, USA
| | - Jansen Seheult
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Vitalant, Pittsburgh, Pennsylvania, USA
| | - Mark Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Vitalant, Pittsburgh, Pennsylvania, USA
| | - Richard M Kaufman
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Rampotas A, Prodger CF, Murphy MF. An assessment of the management of anaemia in acute care settings in the United Kingdom: The value of a collaborative approach. Transfus Med 2021; 31:322-327. [PMID: 34056763 DOI: 10.1111/tme.12789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Patients presenting to acute care settings with anaemia are at risk of inadequate investigation and inappropriate blood transfusion. In collaboration with Haematology Specialty Trainee Audit and Research (HaemSTAR), this study set out to assess current red blood cell (RBC) transfusion practice and anaemia management in acute care settings across the United Kingdom. METHODS AND RESULTS Fifteen different hospitals participated in the study over a period of a month beginning 01 January 2020. Eight-hundred and twenty-eight eligible patients presenting to acute care settings with anaemia received RBC transfusions during this period. Of these, 159 (19.2%) received inappropriate transfusions according to National Institute for Health and Care Excellence guidelines, and 257 (31%) could have been treated with alternatives to transfusion. One-hundred and fifty-four (18.6%) did not have a cause for their anaemia identified by the time they were discharged from hospital, and in over 50% of these cases that was because of inadequate investigation with blood tests, specialist investigation or referral, or both. CONCLUSION This study found that the appropriateness of transfusion and investigation of anaemia in acute care settings warrant improvement and also demonstrates the value of HaemSTAR in facilitating time-efficient collection of high-quality data.
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Affiliation(s)
- Alexandros Rampotas
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford University Graduate Academic School, Oxford, UK
| | - Catherine F Prodger
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michael F Murphy
- NHS Blood and Transplant, Oxford, UK.,National Institute of Health Research Biomedical Research Centre Haematology Theme, Oxford, UK
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Covin R. Techniques of Blood Transfusion. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Storch EK, Rogerson B, Eder AF. Trend in
ABO‐incompatible RBC
transfusion‐related fatalities reported to the
FDA
, 2000‐2019. Transfusion 2020; 60:2867-2875. [DOI: 10.1111/trf.16121] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/03/2020] [Accepted: 09/09/2020] [Indexed: 01/24/2023]
Affiliation(s)
- Emily K. Storch
- Center for Biologics Evaluation and Research U.S. Food and Drug Administration Silver Spring Maryland USA
| | - Beth Rogerson
- Center for Biologics Evaluation and Research U.S. Food and Drug Administration Silver Spring Maryland USA
| | - Anne F. Eder
- Center for Biologics Evaluation and Research U.S. Food and Drug Administration Silver Spring Maryland USA
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17
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Bolton‐Maggs PHB, Watt A. Transfusion errors — can they be eliminated? Br J Haematol 2019; 189:9-20. [DOI: 10.1111/bjh.16256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 12/14/2022]
Affiliation(s)
| | - Alison Watt
- Serious Hazards of Transfusion Manchester Blood Centre Manchester UK
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