PubMed · 2009 · 23 citations · 20 references
MedicineHealth InformaticsHematologyPatient SafetyPatient Safety InformaticsTransfusion MedicineBlood Product DocumentationBlood Transfusion ManagementBlood Transfusion SafetyPatient IdentificationTransfusion ReactionsTransfusion TherapyAbo Blood Group AntigensAbo Blood Group TypingBlood Component CompatibilityBlood Component TraceabilityBlood Product Transfusion SafetyBlood Transfusion IdentificationRed Blood Cell Transfusion SafetyTransfusion Quality Assurance
BACKGROUND: One of the most serious risks of blood transfusions is an error in ABO blood group compatibility, which can cause a haemolytic transfusion reaction and, in the most severe cases, the death of the patient. The frequency and type of errors observed suggest that these are inevitable, in that mistakes are inherent to human nature, unless significant changes, including the use of computerised instruments, are made to procedures. METHODS: In order to identify patients who are candidates for the transfusion of blood components and to guarantee the traceability of the transfusion, the Securblood system (BBS srl) was introduced. This system records the various stages of the transfusion process, the health care workers involved and any immediate transfusion reactions. The patients and staff are identified by fingerprinting or a bar code. The system was implemented within Ragusa hospital in 16 operative units (ordinary wards, day hospital, operating theatres). RESULTS: In the period from August 2007 to July 2008, 7282 blood components were transfused within the hospital, of which 5606 (77%) using the Securblood system. Overall, 1777 patients were transfused. In this year of experience, no transfusion errors were recorded and each blood component was transfused to the right patient. We recorded 33 blocks of the terminals (involving 0.6% of the transfused blood components) which required the intervention of staff from the Service of Immunohaematology and Transfusion Medicine (SIMT). Most of the blocks were due to procedural errors. CONCLUSIONS: The Securblood system guarantees complete traceability of the transfusion process outside the SIMT and eliminates the possibility of mistaken identification of patients or blood components. The use of fingerprinting to identify health care staff (nurses and doctors) and patients obliges the staff to carry out the identification procedures directly in the presence of the patient and guarantees the presence of the doctor at the start of the transfusion.
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Reports of 355 transfusion‐associated deaths: 1976 through 1985
Kathleen Sazama · Transfusion · 1990 · 736 citations
Transfusion errors in New York State: an analysis of 10 years' experience
Jeanne V. Linden, Kathleen Dorman Wagner, Anthony E. Voytovich et al. · Transfusion · 2000 · 412 citations
Medicine, Hematology, Mistake +8
Serious Hazards of Transfusion: A Decade of Hemovigilance in the UK
D. Stainsby, Hilary Jones, Deborah Asher et al. · Transfusion Medicine Reviews · 2006 · 348 citations · Full text
A report of 104 transfusion errors in New York State
Jeanne V. Linden, B Paul, K.P. Dressler · Transfusion · 1992 · 329 citations