Bedside transfusion errors: analysis of 2 years' use of a system to monitor and prevent transfusion errors.

Clerical errors occurring during specimen collection, issue and transfusion of blood are the most common cause of AB0 incompatible transfusions. 40-50% of the transfusion fatalities result from errors in properly identifying the patient or the blood components. The frequency and type of errors observed, despite the implementation of measures to prevent them, suggests that errors are inevitable unless major changes in procedures are adopted. A fail-safe system, which physically prevents the possibility of error, was adopted in January 1993 and concurrently a quality improvement program was implemented to monitor any transfusion errors. Up to December 1994, 10,995 blood units (5,057 autologous and 5,938 allogeneic) were transfused to 3,231 patients. Seventy-one methodological errors(1/155 units) were observed, half of which were concentrated during the first 4 months of introducing the system. However the system detected and avoided four potentially fatal errors (1/2,748 units). Two cases involved the interchanging of recipient sample tubes, 1 case was due to patient misidentification and the other involved misidentification of blood units. In conclusion the system is effective in detecting otherwise undiscovered errors in transfusion practice and can prevent potential transfusion-associated fatalities caused by misidentification of blood units or recipients.

One-year use of the Bloodloc system in an orthopedic institute.

UNLABELLED: Human error in patient or specimen identification due to fatigue, stress and lack of attention by technologists, nurses, interns, and physicians, can cause routinely safety procedures to be circumvented. Clerical errors may occur during the specimen collection, the issue of blood unit and the transfusion of blood. The introduction in an increasing number of hospital of preoperative autologous blood donation programs further increases the chance of error, because a single patient can predeposit multiple units of blood. In this cases there is a greater commitment not only to transfuse any blood unit that is ABO compatible but to transfuse the specific units the patient previously donated for his own use. Human error has been recognized as a significant cause of transfusion-associated fatalities. The persistence of the frequency and type of errors observed in spite of extensive efforts to eradicate them, suggests that errors are inevitable as long as large number of repetitive procedures are performed unless major system changes are adopted. A system (Bloodloc System) that physically prevents the possibility of error was adopted since January 1993 and cuncurrently a quality improvement program (QI) was implemented specifically designed to monitor: 1. the absence of the code on the blood samples, 2. the blood bank error in setting the Bloodloc, 3. the misidentification of blood samples, 4. any attempt to transfuse the wrong blood unit, 5. any attempt to transfuse, the wrong patients. RESULTS: 4895 blood units (2469 autologous and 2426 allogeneic units) were transfused to 1478 patients (849 predeposited an average of 3.3 +/- 2.0 units). The methodological errors (absence of three-letter code on the patient's specimen tube, wrong transcription of the code on the blood sample, wrong setting of the Bloodloc in the blood bank)--41 cases--were limited at the first four months of implementation of the system. In the same period however have been reported 3 potentially fatal errors which have been avoided by the Bloodloc. Two cases of misidentification of blood samples at the moment of the specimen collection, and one attempt to transfuse the wrong units to the wrong patients. CONCLUSIONS: The Bloodloc system is effective in preventing potential transfusion-associated fatalities caused by units or recipients misidentification.