Paul Ashford

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

Sample from wrong patient

Results reported against wrong

patient identifier

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

It should not be used to correct bad practice

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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