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Prevention of bedside errors in transfusion medicine (PROBE-TM) study: a cluster-randomized, matched-paired clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check.

Abstract：

BACKGROUND:Transfusion of the incorrect blood component is a frequent serious incident associated with transfusion and often involves misidentification of the patient and/or the unit of blood. The objective of this study was to assess the effect of a simple intervention designed to improve performance of the bedside check and to observe the durability of any effect. The intervention was a tag on blood bags reminding staff to check the patient's wristband. The tag was positioned in such a way that the transfusionist was required to remove the tag to spike the unit. STUDY DESIGN AND METHODS:The intervention was tested in a multicenter cluster-randomized controlled trial incorporating short-term and long-term follow-up periods. The primary endpoint was the proportion of patients transfused with red cell units for whom the key elements of the bedside check were all correctly completed. RESULTS:Fifteen matched-paired clinical areas at 12 participating hospitals in six countries were included in the trial. Combining data from all participating hospitals, the bedside check was correctly performed in 37 percent of transfusions during the baseline audit period. There was no evidence of a favorable effect of the intervention immediately after its introduction (pooled odds ratio, 1.09; 95% confidence interval, 0.54-2.17). There was similarly no evidence of a favorable effect after continued use of the intervention for an additional 8 weeks. CONCLUSIONS:A simple intervention in the form of a barrier warning label on blood bags reminding staff to check the patient's wristband failed to improve bedside transfusion practice. The robust study design developed for this study could be applied to investigate other interventions to improve the safety of bedside transfusion practice.

journal_name

Transfusion

journal_title

Transfusion

authors

Murphy MF,Casbard AC,Ballard S,Shulman IA,Heddle N,Aubuchon JP,Wendel S,Thomson A,Hervig T,Downes K,Carey PM,Dzik WH,BEST Research Collaborative.

doi

10.1111/j.1537-2995.2007.01189.x

subject

Has Abstract

pub_date

2007-05-01 00:00:00

pages

771-80

issue

eissn

0041-1132

issn

1537-2995

pii

TRF01189

journal_volume

pub_type

杂志文章,多中心研究,随机对照试验

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Prevention of bedside errors in transfusion medicine (PROBE-TM) study: a cluster-randomized, matched-paired clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check.