Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors.

Abstract:

OBJECTIVE:To determine whether the use of a computerized bar code-based blood identification system resulted in a reduction in transfusion errors or near-miss transfusion episodes. PATIENTS AND METHODS:Our institution instituted a computerized bar code-based blood identification system in October 2006. After institutional review board approval, we performed a retrospective study of transfusion errors from January 1, 2002, through December 31, 2005, and from January 1, 2007, through December 31, 2010. RESULTS:A total of 388,837 U were transfused during the 2002-2005 period. There were 6 misidentification episodes of a blood product being transfused to the wrong patient during that period (incidence of 1 in 64,806 U or 1.5 per 100,000 transfusions; 95% CI, 0.6-3.3 per 100,000 transfusions). There was 1 reported near-miss transfusion episode (incidence of 0.3 per 100,000 transfusions; 95% CI, <0.1-1.4 per 100,000 transfusions). A total of 304,136 U were transfused during the 2007-2010 period. There was 1 misidentification episode of a blood product transfused to the wrong patient during that period when the blood bag and patient's armband were scanned after starting to transfuse the unit (incidence of 1 in 304,136 U or 0.3 per 100,000 transfusions; 95% CI, <0.1-1.8 per 100,000 transfusions; P=.14). There were 34 reported near-miss transfusion errors (incidence of 11.2 per 100,000 transfusions; 95% CI, 7.7-15.6 per 100,000 transfusions; P<.001). CONCLUSION:Institution of a computerized bar code-based blood identification system was associated with a large increase in discovered near-miss events.

journal_name

Mayo Clin Proc

journal_title

Mayo Clinic proceedings

authors

Nuttall GA,Abenstein JP,Stubbs JR,Santrach P,Ereth MH,Johnson PM,Douglas E,Oliver WC Jr

doi

10.1016/j.mayocp.2012.12.010

subject

Has Abstract

pub_date

2013-04-01 00:00:00

pages

354-9

issue

4

eissn

0025-6196

issn

1942-5546

pii

S0025-6196(13)00034-7

journal_volume

88

pub_type

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