Exponential error reduction in pretransfusion testing with automation.

BACKGROUND: Protecting the safety of blood transfusion is the top priority of transfusion service laboratories. Pretransfusion testing is a critical element of the entire transfusion process to enhance vein-to-vein safety. Human error associated with manual pretransfusion testing is a cause of transfusion-related mortality and morbidity and most human errors can be eliminated by automated systems. However, the uptake of automation in transfusion services has been slow and many transfusion service laboratories around the world still use manual blood group and antibody screen (G&S) methods. STUDY DESIGN AND METHODS: The goal of this study was to compare error potentials of commonly used manual (e.g., tiles and tubes) versus automated (e.g., ID-GelStation and AutoVue Innova) G&S methods. Routine G&S processes in seven transfusion service laboratories (four with manual and three with automated G&S methods) were analyzed using failure modes and effects analysis to evaluate the corresponding error potentials of each method. RESULTS: Manual methods contained a higher number of process steps ranging from 22 to 39, while automated G&S methods only contained six to eight steps. Corresponding to the number of the process steps that required human interactions, the risk priority number (RPN) of the manual methods ranged from 5304 to 10,976. In contrast, the RPN of the automated methods was between 129 and 436 and also demonstrated a 90% to 98% reduction of the defect opportunities in routine G&S testing. CONCLUSION: This study provided quantitative evidence on how automation could transform pretransfusion testing processes by dramatically reducing error potentials and thus would improve the safety of blood transfusion.

The 360 degrees nature of change implementation and the essential three Ds for successful and sustainable change.

The challenge and real key to future success is to be more than just receptive to change. Lasting success will come to those that encourage innovation and create change. But most of our organizations have not been successful at implementing change initiatives, let alone sustaining them. We fail to recognize that change is a process that requires definition, decisiveness, and leadership to deliver the success and sustainability we so badly need. Successful and sustainable change can happen with the "3 Ds": define, decide, and deliver. Making sure that change is successful is every stakeholder's responsibility, and making change sustainable is something that must be driven by leadership.