Audit of transfusion procedures in 660 hospitals. A College of American Pathologists Q-Probes study of patient identification and vital sign monitoring frequencies in 16494 transfusions

Preventing Mistransfusions: An Evaluation of Institutional Knowledge and a Response

BACKGROUND

Blood product mistransfusions occur when a process error causes transfusion of incompatible blood products. These events are known sources of negative patient outcomes. One such event demonstrated an institutional knowledge gap and an opportunity to reduce this source of transfusion errors. The focus of this study was to evaluate the application of point of care cognitive aids to bridge potentially lethal knowledge gaps in blood product to patient compatibility.

METHODS

A patient-donor ABO antigen compatibility grid for red blood cells (RBC) and fresh frozen plasma (FFP) was developed for creation of a cognitive aid and a blood product safety quiz. Participants included 117 registered nurses and postgraduate medical interns who were given 2 minutes to complete the quiz for establishing institutional controls. A separate group of 111 registered nurses and interns were given the same timed quiz twice, without and then with a blood product compatibility cognitive aid. An analysis of covariance was used to evaluate without cognitive aid versus with cognitive aid quiz results while taking the specialty (nurse versus interns) and baseline score into consideration. The blood bank adopted the grid as a forcing function to be completed before release of blood products.

RESULTS

The correct RBC answer percentage increased from 84.7% to 98.3% without and with cognitive aid (average improvement 13.6%, standard deviation [SD] = 18.3%, 95% confidence interval, 10.1%-17.1%, P < .0001, ); the correct FFP answer percentage increased from 54.2% to 99.6% without and with cognitive aid (average improvement 45.4%, SD = 20.1%, 95% confidence interval, 41.7%-49.2%, P < .0001). Participants with lower baseline RBC and FFP score showed better improvement in the correct answer percentage for RBC and FFP (P < .001), respectively.

CONCLUSIONS

The use of a cognitive aid for determining blood product ABO compatibility may improve performance during a time-limited test for matching correct patient and blood product ABO type. The use of the cognitive aid as a "forcing function" before the release of blood from the blood bank and before transfusion at the bedside may reduce transfusion mismatch associated with gaps in ABO compatibility knowledge.

Assessment of bedside transfusion practices at a tertiary care center: A step closer to controlling the chaos

BACKGROUND:

Blood transfusion chain can be divided into three phases: preanalytical (patient bedside), analytical (steps done at transfusion services), and postanalytical (bedside). Majority (~70%) of events due to blood transfusion have been attributed to errors in bedside blood administration practices. Survey of bedside transfusion practices (pre-analytical and post analytical phase) was done to assess awareness and compliance to guidelines regarding requisition and administration of blood components.

MATERIALS AND METHODS:

Interview-based questionnaire of ward staff and observational survey of actual transfusion of blood components in total 26 wards of the institute was carried out during November–December 2013. All the collected data were coded (to maintain confidentiality) and analyzed using SPSS (v 20). For analysis, wards were divided into three categories: medical, surgical, and others (including all intensive care units).

RESULTS:

A total of 104 (33 resident doctors and 71 nursing) staff members were interviewed and observational survey could be conducted in 25 wards during the study period. In the preanalytical phase, major issues were as follows: lack of awareness for institute guidelines (80.6% not aware), improper sampling practices (67.3%), and prescription related (56.7%). In the postanalytical phase, major issues were found to be lack of consent for blood transfusion (72%), improper warming of blood component (~80%), and problems in storage and discarding of blood units.

CONCLUSION:

There is need to create awareness about policies and guidelines of bed side transfusion among the ward staff. Regular audits are necessary for compliance to guidelines among clinical staff.

Retrospective evaluation of the effect of red blood cell product age on occurrence of acute transfusion-related complications in dogs: 210 cases (2010-2012)

OBJECTIVE

To determine whether red blood cell (RBC) product age influences the occurrence of acute transfusion-related complications and mortality in dogs. The hypothesis was that acute transfusion-related complications and mortality would increase with age of product.

DESIGN

Retrospective study (2010-2012).

SETTING

University teaching hospital.

ANIMALS

Two hundred and ten clinical canine patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Medical records were reviewed for dogs receiving RBC-containing products. Patient signalment; reason for transfusion; product type, dose, age, and source; pretransfusion compatibility; rate, route, and method of administration; administration of multiple transfusions; underlying disease; occurrence of transfusion-related complications (eg, fever, hemolysis, gastrointestinal distress, cardiovascular, neurologic, and respiratory complications); various hematologic parameters; and survival were recorded. Data were analyzed for association between potential risk factors and occurrence of transfusion-related complications as well as between transfusion-related complications and survival. Of 333 transfusion events in 210 patients, 84 transfusion-related complications occurred. Fever was most common (41/333), followed by hemolysis (21/333). For every additional day of product age, the odds of hemolysis increased significantly (odds ratio, 1.11; 95% confidence interval, 1.06-1.16; P < 0.0001). Transfusion-related complications when considered as a whole were associated with higher dose of product, longer duration of administration per transfusion event, and immune-mediated disease, but not with source of product or general category of anemia. Administration rate was significantly slower in patients with febrile transfusion-related complications (P < 0.0001). Product age was not associated with increased mortality.

CONCLUSIONS

Age of stored RBC products is associated with increased risk of transfusion-related hemolysis, but not with fever. Prospective clinical studies evaluating the influence of storage duration on development of in vitro versus in vivo hemolysis are warranted.

Twenty-five years of accomplishments of the College of American Pathologists Q-probes program for clinical pathology

CONTEXT

During the past 25 years, the College of American Pathologists' (CAP) Q-Probes program has been available as a subscription program to teach laboratorians how to improve the quality of clinical laboratory services.

OBJECTIVE

To determine the accomplishments of the CAP Q-Probes program.

DESIGN

We reviewed Q-Probes participant information, study data and conclusions, author information, and program accomplishments.

RESULTS

During this time 117 Q-Probes clinical pathology studies were conducted by 54 authors and coauthors, 42,899 laboratories enrolled from 24 countries, 98 peer-reviewed publications occurred and were cited more than 1600 times, and the studies were featured 59 times in CAP Today. The most frequent studies (19) focused on turnaround times for results or products at specific locations (emergency department, operating room, inpatients, outpatients), specific diseases (acute myocardial infarction, urinary tract), availability for specific events such as morning rounds or surgery, a specific result (positive blood cultures), and a method on how to use data for improvement (stat test outliers). Percentile ranking of study participants with better performance provided benchmarks for each study with attributes statistically defined that influenced improved performance. Other programs, such as an ongoing quality improvement program (Q-Tracks), a laboratory competency assessment program, a pathologist certification program, and an ongoing physician practice evaluation program (Evalumetrics), have been developed from Q-Probes studies.

CONCLUSIONS

The CAP's Q-Probes program has made significant contributions to the medical literature and has developed a worldwide reputation for improving the quality of clinical pathology services worldwide.

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.

Developing performance measures for patient blood management

In 2005, The Joint Commission set about assessing the need for performance measures associated with the provision of blood products. Through a rigorous process, seven patient blood management performance measures were created. These measures incorporated a measure requiring transfusion consent; three measures requiring the combination of a laboratory value and a rationale for transfusion of plasma, platelets, or red blood cells; a measure requiring standard documentation about a transfusion; a measure evaluating preoperative anemia screening; and a measure of preoperative type screening and antibody testing before the start of major blood loss surgery. This article describes the process of this measure development and summarizes the final measures and some of the evidence supporting the measures.

Nurses' practice of blood transfusion in the United Arab Emirates: an observational study

AIMS

The aim of this study was to document nurses' practice of red blood cells transfusion.

BACKGROUND

In the United Arab Emirates hospitals, nurses are responsible for the administration of blood transfusions. The safety and effectiveness of the transfusion process is dependent, among others, on the knowledge and skills of nurses who perform the procedure. Poor practice may result in avoidable complications that may threaten patients' safety. Published work indicated that nurses' practice varied across contexts and highlighted that patients received suboptimal care and incorrect transfusion that culminated in death or morbidity. In the United Arab Emirates, publications related to nurses' practice of blood transfusion are lacking.

DESIGN

Descriptive.

METHODS

Data were collected by means of non-participant structured observation. Data collection was undertaken in two general public hospitals in the Emirate of Abu Dhabi, United Arab Emirates. A random sample of 50 nurses from both hospitals was selected. Each nurse was observed once, from 10 minutes prior to blood collection until 15 minutes after initiating a transfusion.

RESULTS

Forty-nine nurses (98%) were observed. The maximum obtained score was 13 points of a possible score of 21, and 75% of nurses scored below the 50% level. Practice deficiencies included improper patient identification, suboptimal vital signs documentation and invalid methods of blood warming.

CONCLUSIONS

Patients in both hospitals were at risk of receiving incorrect blood, suffering unobserved transfusion reaction and acquiring bacterial infection.

RELEVANCE TO CLINICAL PRACTICE

This study revealed inadequate practices that nurses and hospitals should strive to change to provide a safer and more effective care that would, hopefully, minimise the risks and maximise the benefits of blood transfusion. These findings also have implications for clinical supervision and nurse education.

Bar code-based pre-transfusion check in pre-operative autologous blood donation

BACKGROUND

The objective of this study was to demonstrate the feasibility of a bar code-based identification system for the pre-transfusion check at the bedside in the setting of pre-operative autologous blood donation (PABD).

MATERIALS AND METHODS

Between July 2003 and December 2008 we determined the compliance rate and causes of failure of electronic bedside checking for PABD transfusion.

RESULTS

A total of 5627 (9% of all transfusions) PABD units were administered without a single mistransfusion. The overall rate of compliance with electronic checking was 99%.

CONCLUSIONS

The bar code-based identification system was applicable to the pre-transfusion check for PABD transfusion.

Educating medical students in laboratory medicine: a proposed curriculum

As the 100th anniversary of the Flexner report nears, medical student education is being reviewed at many levels. One area of concern, expressed in recent reports from some national health care organizations, is the adequacy of training in the discipline of laboratory medicine (also termed clinical pathology). The Academy of Clinical Laboratory Physicians and Scientists appointed an ad hoc committee to review this topic and to develop a suggested curriculum, which was subsequently forwarded to the entire membership for review. The proposed medical student laboratory medicine curriculum defines goals and objectives for training, provides guidelines for instructional methods, and gives examples of how outcomes can be assessed. This curriculum is presented as a potentially helpful outline for use by medical school faculty and curriculum committees.

Laboratory medicine quality indicators: a review of the literature

We summarize information on quality indicators related to laboratory testing from published literature and Internet sources to assess current gaps with respect to stages of the laboratory testing process, the Institute of Medicine (IOM) health care domains, and quality measure evaluation criteria. Our search strategy used various general and specific terms for clinical conditions and laboratory procedures. References related to a potential quality indicator associated with laboratory testing and an IOM health care domain were included. With the exception of disease- and condition-related indicators originating from clinical guidelines, the laboratory medicine quality indicators reviewed did not satisfy minimum standard evaluation criteria for quality or performance measures (ie, importance, scientific acceptability, and feasibility) and demonstrated a need across the total laboratory testing process for consistently specified, useful, and evidence-based, laboratory-related quality and performance measures that are important to health outcomes and meaningful to health care stakeholders for which laboratories can be held accountable.

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.

A computer-assisted transfusion management system and changed transfusion practices contribute to appropriate management of blood components

BACKGROUND

ABO-incompatible blood transfusions attributable to inadequate identification (ID) of the patient or the blood unit are among the most serious of transfusion hazards. It has been unclear whether a computer-assisted transfusion management system connected to a bar code ID system could contribute to the appropriate management of blood components, as well as to the prevention of mistransfusions.

STUDY DESIGN AND METHODS

A transfusion management system has been developed that links the hospital information system, a bar code patient-blood unit ID system, and an automated device for pretransfusion testing. The guidelines for issuing blood components from the transfusion service were also changed. The appropriateness of blood management was evaluated by monitoring the time to initiate transfusion after issuing a blood unit from the transfusion service (time after issuing [TAI]) and by calculating the number of units issued and subsequently returned, as well as the rate of date-expired red cell (RBC) components.

RESULTS

From July 2002 to December 2006, a total of 49,974 blood components were transfused without a single mistransfusion. The monitoring of TAI and the notice to use the issued blood immediately had the effect of shortening TAI in the inpatient ward. The number of issued and subsequently returned RBC components, as well as the rate of date-expired RBC components, decreased significantly after the introduction of the system.

CONCLUSION

A computer-assisted transfusion management system and changing transfusion practices appear useful in preventing mistransfusions and in contributing to the appropriate management of blood components.

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

BACKGROUND

Transfusion of the incorrect blood component is a frequent serious incident associated with transfusion and often involves misidentification of the patient and/or the unit of blood. The objective of this study was to assess the effect of a simple intervention designed to improve performance of the bedside check and to observe the durability of any effect. The intervention was a tag on blood bags reminding staff to check the patient's wristband. The tag was positioned in such a way that the transfusionist was required to remove the tag to spike the unit.

STUDY DESIGN AND METHODS

The intervention was tested in a multicenter cluster-randomized controlled trial incorporating short-term and long-term follow-up periods. The primary endpoint was the proportion of patients transfused with red cell units for whom the key elements of the bedside check were all correctly completed.

RESULTS

Fifteen matched-paired clinical areas at 12 participating hospitals in six countries were included in the trial. Combining data from all participating hospitals, the bedside check was correctly performed in 37 percent of transfusions during the baseline audit period. There was no evidence of a favorable effect of the intervention immediately after its introduction (pooled odds ratio, 1.09; 95% confidence interval, 0.54-2.17). There was similarly no evidence of a favorable effect after continued use of the intervention for an additional 8 weeks.

CONCLUSIONS

A simple intervention in the form of a barrier warning label on blood bags reminding staff to check the patient's wristband failed to improve bedside transfusion practice. The robust study design developed for this study could be applied to investigate other interventions to improve the safety of bedside transfusion practice.

Increasing patient safety and efficiency in transfusion therapy using formal process definitions

The administration of blood products is a common, resource-intensive, and potentially problem-prone area that may place patients at elevated risk in the clinical setting. Much of the emphasis in transfusion safety has been targeted toward quality control measures in laboratory settings where blood products are prepared for administration as well as in automation of certain laboratory processes. In contrast, the process of transfusing blood in the clinical setting (ie, at the point of care) has essentially remained unchanged over the past several decades. Many of the currently available methods for improving the quality and safety of blood transfusions in the clinical setting rely on informal process descriptions, such as flow charts and medical algorithms, to describe medical processes. These informal descriptions, although useful in presenting an overview of standard processes, can be ambiguous or incomplete. For example, they often describe only the standard process and leave out how to handle possible failures or exceptions. One alternative to these informal descriptions is to use formal process definitions, which can serve as the basis for a variety of analyses because these formal definitions offer precision in the representation of all possible ways that a process can be carried out in both standard and exceptional situations. Formal process definitions have not previously been used to describe and improve medical processes. The use of such formal definitions to prospectively identify potential error and improve the transfusion process has not previously been reported. The purpose of this article is to introduce the concept of formally defining processes and to describe how formal definitions of blood transfusion processes can be used to detect and correct transfusion process errors in ways not currently possible using existing quality improvement methods.

New technology for transfusion safety

Hemovigilance programs from around the world document that the greatest risk to recipients of blood transfusion is human error, resulting in transfusion of the incorrect blood component. Errors in transfusion care have strong parallels with errors in medication administration. Errors often result from 'lapse' or 'slip' mistakes in which details of patient identification are overlooked. Three areas of transfusion are focal points for improved care: the labelling of the patient's pre-transfusion sample, the decision to transfuse and the final bedside check designed to prevent mis-transfusion. Both barcodes and radio-frequency identification technology, each ideally suited to matching alpha-numeric identifiers, are being implemented in order to improve performance sample labelling and the bedside check. The decision to transfuse should ultimately be enhanced through the use of nanotechnology sensors, computerised order entry and decision support systems. Obstacles to the deployment of new technology include resistance to change, confusion regarding the best technology, and uncertainty regarding the return-on-investment. By focusing on overall transfusion safety, deploying validated systems appropriate for both medication and blood administration, thoughtful integration of technology into bedside practice and demonstration of improved performance, the application of new technologies will improve care for patients in need of transfusion therapy.

Errors in laboratory medicine: practical lessons to improve patient safety

CONTEXT

Patient safety is influenced by the frequency and seriousness of errors that occur in the health care system. Error rates in laboratory practices are collected routinely for a variety of performance measures in all clinical pathology laboratories in the United States, but a list of critical performance measures has not yet been recommended. The most extensive databases describing error rates in pathology were developed and are maintained by the College of American Pathologists (CAP). These databases include the CAP's Q-Probes and Q-Tracks programs, which provide information on error rates from more than 130 interlaboratory studies.

OBJECTIVES

To define critical performance measures in laboratory medicine, describe error rates of these measures, and provide suggestions to decrease these errors, thereby ultimately improving patient safety.

SETTING

A review of experiences from Q-Probes and Q-Tracks studies supplemented with other studies cited in the literature.

DESIGN

Q-Probes studies are carried out as time-limited studies lasting 1 to 4 months and have been conducted since 1989. In contrast, Q-Tracks investigations are ongoing studies performed on a yearly basis and have been conducted only since 1998. Participants from institutions throughout the world simultaneously conducted these studies according to specified scientific designs. The CAP has collected and summarized data for participants about these performance measures, including the significance of errors, the magnitude of error rates, tactics for error reduction, and willingness to implement each of these performance measures.

MAIN OUTCOME MEASURES

A list of recommended performance measures, the frequency of errors when these performance measures were studied, and suggestions to improve patient safety by reducing these errors.

RESULTS

Error rates for preanalytic and postanalytic performance measures were higher than for analytic measures. Eight performance measures were identified, including customer satisfaction, test turnaround times, patient identification, specimen acceptability, proficiency testing, critical value reporting, blood product wastage, and blood culture contamination. Error rate benchmarks for these performance measures were cited and recommendations for improving patient safety presented.

CONCLUSIONS

Not only has each of the 8 performance measures proven practical, useful, and important for patient care, taken together, they also fulfill regulatory requirements. All laboratories should consider implementing these performance measures and standardizing their own scientific designs, data analysis, and error reduction strategies according to findings from these published studies.

Technology for enhanced transfusion safety

Data from reporting systems around the world document that non-infectious hazards are the leading cause of serious morbidity or mortality resulting from blood transfusion. Among these non-infectious hazards, mis-transfusion represents the most frequently observed serious hazard and occurs at an estimated rate of 1 in 14,000 transfusions. Mis-transfusion events result from "lapse errors" (slip ups) rather than cognitive mistakes. Lapse errors are more likely to occur during repetitive tasks when individuals are distracted, rushed, or fatigued--conditions to which machines are not susceptible. The final bedside check and the collection of patient samples for pre-transfusion testing are key "error spots" and are candidates for new technology innovation. Existing technology includes non-computerized devices; bedside devices based on bar code technology; and the use of radiofrequency chips. Several commercial systems employing bar-code technology have reached clinical application or are undergoing refinement. Radiofrequency-based systems are on the near horizon. Nearly all systems begin with the application of machine-readable data to the patient's wristband. The third error spot--the decision to transfuse--will be a challenging area for future application of information technology. Computerized physician order-entry, decision support and ultimately active computer-based decision-making are expected to enhance transfusion decisions. Despite the explosive growth in information technology in modern society, healthcare has lagged behind many other sectors in the use of enhanced information technology. Studies are needed to identify which technologies improve patient outcomes. Healthcare workers, administrators, and regulators need to embrace the use of new technology in order to reduce errors and improve safety for patients.

Detecting and preventing the occurrence of errors in the practices of laboratory medicine and anatomic pathology: 15 years' experience with the College of American Pathologists' Q-PROBES and Q-TRACKS programs

This review extracts those studies from the CAP Q-PROBES and Q-TRACKS programs that have benchmarked and monitored the occurrence of errors in the practices of laboratory medicine and anatomic pathology. The outcomes of these studies represent in aggregate the analysis of millions of data points collected in thousands of hospitals throughout the United States. Also presented in this review are hospital and laboratory practices associated with improved performance (ie, fewer errors). Only those associations that were shown to be statistically significant are presented. They represent only a small fraction of the practices examined in these studies. The reader is encouraged to peruse the Q-PROBES studies cited in the reference list to learn about the wide range of practices investigated. The institution of some of these practices for which the associated error reductions were not statistically significant might nonetheless improve performance in some environments. There is no way of knowing whether some better-performing institutions compensated for not employing presumably beneficial practices by applying other practices about which the studies' authors neglected to inquire. Nor is there any way of knowing whether institutions in which performance was poor employed presumably beneficial practices, but possessed operational flaws about which the studies' authors neglected to inquire. Certainly, hospitals operating in the bottom 10% of benchmarked performances would do well to investigate the possibility that some of these practices might reduce the incidence of errors in their institutions. From the results of these studies, there emerge two complementary strategies that appear to be associated with reduction of errors. Obviously, the first strategy involves doing what is necessary to prevent the occurrence of errors in the first place. Several tactics may accomplish this goal. Healthcare workers responsible for specific tasks must be properly educated and motivated to perform those tasks with as few errors as possible. There must be written policies and protocols detailing responsibilities and providing contingencies when those responsibilities are not met. The successful completion of required tasks must be documented, especially those tasks that are performed as requisite to others. In other words, it should be impossible to move on to subsequent operations in testing processes before documenting the successful completion of previous requisite operations. Finally, the opportunities for making errors must be reduced. Specifically, the number of steps in which specimens are delivered to laboratories, tests are performed, and results are disseminated to those who use them must be reduced as much as possible. The second strategy involves the assumption that despite our best efforts to prevent them, errors will occur. No matter how smart we are, no matter how careful we try to be, we will make mistakes. It is essential that systems designed to eliminate errors include elements of redundancy to catch those mistakes. Work must be checked and verified before therapeutic decisions are finalized. This is especially true when those decisions are irrevocable and the potential damage caused by errors cannot be undone. Ideally, systems that use redundancy should include provisions to shut down the testing process altogether when the successful execution of previous steps cannot be verified. Once error detection systems are established, service providers can gauge their performance by employing tools of continuous monitoring to assess the degree to which health care workers comply with required procedures, and with which services achieve their intended outcomes.

Barcode identification for transfusion safety

PURPOSE OF REVIEW

Errors related to blood transfusion in hospitals may produce catastrophic consequences. This review addresses potential solutions to prevent patient misidentification including the use of new technology, such as barcoding.

RECENT FINDINGS

A small number of studies using new technology for the transfusion process in hospitals have shown promising results in preventing errors. The studies demonstrated improved transfusion safety and staff preference for new technology such as bedside handheld scanners to carry out pretransfusion bedside checking. They also highlighted the need for considerable efforts in the training of staff in the new procedures before their successful implementation.

SUMMARY

Improvements in hospital transfusion safety are a top priority for transfusion medicine, and will depend on a combined approach including a better understanding of the causes of errors, a reduction in the complexity of routine procedures taking advantage of new technology, improved staff training, and regular monitoring of practice. The use of new technology to improve the safety of transfusion is very promising. Further development of the systems is needed to enable staff to carry out bedside transfusion procedures quickly and accurately, and to increase their functionality to justify the cost of their wider implementation.

Patient safety and blood transfusion: new solutions

Current risk from transfusion is largely because of noninfectious hazards and defects in the overall process of delivering safe transfusion therapy. Safe transfusion therapy depends on a complex process that requires integration and coordination among multiple hospital services including laboratory medicine, nursing, anesthesia, surgery, clerical support, and transportation. The multidisciplinary hospital transfusion committee has been traditionally charged with oversight of transfusion safety. However, in recent years, this committee may have been neglected in many institutions. Resurgence in hospital oversight of patient safety and transfusion efficacy is an important strategy for change. A new position, the transfusion safety officer (TSO), has been developed in some nations to specifically identify, resolve, and monitor organizational weakness leading to unsafe transfusion practice. New technology is becoming increasingly available to improve the performance of sample labeling and the bedside clerical check. Several technology solutions are in various stages of development and include wireless handheld portable digital assistants, advanced bar coding, radiofrequency identification, and imbedded chip technology. Technology-based solutions for transfusion safety will depend on the larger issue of the technology for patient identification. Devices for transfusion safety hold exciting promise but need to undergo clinical trials to show effectiveness and ease of use. Technology solutions will likely require integration with delivery of pharmaceuticals to be financially acceptable to hospitals.