2009 · 15 citations · 9 references
Health ProfessionsBiomedical InformaticsHealth InformaticsClinical InformaticsPatient SafetyTransfusion MedicineBlood CollectionBlood Product DocumentationBlood Transfusion ManagementBlood Transfusion SafetyElectronic Data Capture SystemsPatient IdentificationBlood Bank Information SystemsBlood Bank ManagementBlood Component IssuanceIdentification SystemsPatient WristbandsPre-transfusion Patient AssessmentTransfusion Error PreventionTransfusion Order
BACKGROUND: Blood safety must be maintained throughout the whole transfusion chain to prevent the transfusion of incorrect blood components. The estimated risk of an incorrect transfusion is in the order of 1 per 10,000 units of blood. Although several kinds of errors contribute to "wrong blood" events, 70% of errors occur in clinical areas with the most common being due to failure of the pre-transfusion bedside checking procedure. MATERIALS AND METHODS: Several methods are available to reduce such errors. The I-TRAC Plus system by Immucor consists of an identification bracelet which is a bar-coded wristband and a handheld portable computer that identifies patients and blood bags by a scanner and prints the information through a portable printer. The labels attached on the blood order forms and on the sample tubes are read and recorded in the blood bank's informatics system (EmoNet INSIEL). Labels showing the bar-code of the assigned number, which includes the ID number of the patient, the ID number of the unit and a code identifying the kind of product and use (allogeneic or autologous), are generated and applied to the blood components. The transfusions are administered after checking the unit and the patient's wristband using the scanner of a portable PC. RESULTS: In 5 years a total of 71,400 units of blood components were transfused to 15,430 patients using the I-TRAC Plus system. The system prevented 12 cases of mis-identification of patients (5 in 2003, 0 in 2004, 1 in 2005, 1 in 2006 and 5 in 2007). CONCLUSIONS: In 2003 we introduced the use of a bar-code matching system between a patient's wristband and the blood bag to avoid mistakes at the bedside. In 5 years the system provided benefits by avoiding errors in the identification of patients, thus preventing "wrong blood" transfusions.
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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
Emily Cooley Lecture 2002: transfusion safety in the hospital
Transfusion · 2003 · 144 citations