paul ashford. safe blood? ensuring the provision of safe blood is a high priority donor selection...
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Safe Blood?Ensuring the provision of safe blood is a high
priorityDonor selectionTestingProcessingQuality assurance
But...
Safe Blood?Ensuring the provision of safe blood is a high
priorityDonor selectionTestingProcessingQuality assurance
But...Safe blood given to the wrong recipient can
cause death or serious injury
Is there a problem?You won’t find a problem if you don’t look for
itHaemovigilance systems consistently show
that the most frequent errors are ‘Incorrect blood component transfused’
Identification is the keyAt each step of the transfusion process, and
every other intervention in medicine, identification of the right patient is an absolute essential.
SHOT Report 2011
Sample from wrong patient
Results reported against wrong
patient identifier
Patient incorrectly identified
Sample from wrong patient
Patient incorrectly identified
Request carries wrong patient
identifier
Results reported against wrong
patient identifier
Sample from wrong patient
Patient incorrectly identified
Request carries wrong patient
identifier
Sample from wrong patient
Results reported against wrong
patient identifier
Sample from wrong patient
Patient incorrectly identified
Request carries wrong patient
identifier
Samples incorrectly identified
Sample from wrong patient
Results reported against wrong
patient identifier
Sample from wrong patient
Patient incorrectly identified
Request carries wrong patient
identifier
Samples incorrectly identified
Patient incorrectly matched to products
Sample from wrong patient
Results reported against wrong
patient identifier
Types of ErrorTranscription errors
569237 becomes 569327Inconsistent or missing identifiers
Hospital number; family name; forename; DoB Confusion of identifiers
Penny Alison or Alison Penny? (The strange case of Penny Allison)
Wrong source of informationInadequate checking
Manual InterventionsConsistent policies and proceduresAdequate training and refreshersPatient wristbandsSufficient identifiers (with redundancy)Double checkingAppropriate working conditionsPolicies for handling errors
Automation InterventionsBar coding of blood productsElectronically readable patient wristbandsControl software
Bar coding of blood productsBoth machine
readable and clear text
Standard designUse of ISBT 128
international standard
Linked automated data capture and effective blood management systems
Patient WristbandsElectronic
identification of the patient
Electronic and human readable
Reduces likelihood of identification error
ISBT 128 data structures
Patient WristbandsReduces likelihood
of identification error – provided it is attached to the correct patient!!!
Wristband controlsWristband only to be assigned by specified
well trained staffThorough patient identification procedure
prior to printing and affixing wristbandWritten procedures regarding removal and
re-issue of wristbandsPatient education regarding importance of
wristband
Scanners and control systemsBedside scanning
systems to capture electronic information
Control software linking all phases of the information cycle
Norwegian ISBT 128 SystemBased on ISBT 128 Technical Bulletin 8Patient has bar coded wristbandBlood unit is ISBT 128 labelledPatient wristband scanned at sample
collection – tube label generatedBlood bank selects compatible blood and
generates two part ‘match with unit label’, confirming correct unit
At bedside ‘match with unit’ label scanned and patient wristband
Oxford Hospital SystemSimilar approach to Norwegian systemHas additional security of controlled
refrigerator accessSuitable for ‘remote issue’ situationsStaves et al. Transfusion 2008;48:415-424
End-to-end electronic transfusion Bar-coded patient ID on the wristband is used to label the sample and blood bagDavies et al. Transfusion 2006; 46: 352-364
slide courtesy of Prof Mike Murphy
Scanned patient ID
Patient ID automatically
associated with request at bedside
Samples automatically
labelled with bar codes at point of
collection
Scanned patient ID
Confirmed match with blood and
reports
Scanned patient ID
Correct patient confirmed
Patient ID transferred
automatically to crossmatch report
and blood unit label
Scanned patient ID
Patient ID automatically
associated with request at bedside
Samples automatically
labelled with bar codes at point of
collection
Scanned patient ID
Confirmed match with blood and
reports
Scanned patient ID
Correct patient confirmed
Patient ID transferred
automatically to crossmatch report
and blood unit label
???
???
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