ABSTRACT
A multidisciplinary safety initiative transformed blood transfusion practices at St. Luke's Episcopal Hospital in Houston, Texas. An intense analysis of a mistransfusion using the principles of a Just Culture and the process of Cause Mapping identified system and human performance factors that led to the transfusion error. Multiple initiatives were implemented including technology, education and human behaviour change. The wireless technology of Pyxis Transfusion Verification by CareFusion is effective with the rapid infusion module efficient for use in critical care. Improvements in blood transfusion safety were accomplished by thoroughly evaluating the process of transfusions and by implementing wireless electronic transfusion verification technology. During the 27 months following implementation of the CareFusion Transfusion Verification there have been zero cases of transfusing mismatched blood.
Subject(s)
Blood Transfusion , Critical Care/organization & administration , Medical Errors/prevention & control , Outcome and Process Assessment, Health Care/organization & administration , Patient Identification Systems/organization & administration , Safety Management/organization & administration , Aged , Blood Transfusion/nursing , Computers, Handheld , Female , Hemoglobinuria, Paroxysmal , Hospitals, Religious , Hospitals, Teaching , Humans , Medical Errors/adverse effects , Medical Errors/nursing , Patient Care Team , Systems Analysis , Texas , Total Quality Management/organization & administration , Transfusion ReactionABSTRACT
We describe a multipronged, multidisciplinary effort to improve the safety of blood transfusion in our hospital. System-wide practices related to the ordering, delivery, and transfusion of blood products were addressed including: (1) appropriate selection of patients and utilization of blood, (2) accurate blood product labeling and tracking, (3) reliable transportation of blood products between the transfusion service laboratory and the bedside, (4) electronic verification of patients and products at the point of transfusion, and (5) documentation of transfusion events in the patient's medical record. By implementing new technologies and focusing LEAN process improvement techniques on the preanalytical, analytical, and postanalytical phases of the transfusion cycle, we have been able to significantly reduce the risk of transfusion error in our patient population.
