Thomas Frietsch1, Daffyd Thomas2, Michael Schöler3, Birgit Fleiter4, Martin Schipplick5, Michael Spannagl6, Ralf Knels7, Xuan Nguyen8. 1. Department of Anesthesiology and Critical Care Medicine, Diakonissenkrankenhaus Mannheim, Teaching Hospital of the University Medicine Mannheim, University of Heidelberg, Mannheim, Germany. 2. Department of Anaesthesia and Critical Care, Morriston Hospital, Swansea, Wales, UK. 3. Department of Anesthesiology and Surgical Intensive Care Medicine, University Medical Center Mannheim, Mannheim, Germany. 4. DRK Blutspendedienst West, Nordrhein, Germany. 5. Department of Anesthesiology and Critical Care Medicine, Krankenhaus Leonberg, Leonberg, Germany. 6. Department of Hemostasis and Transfusion Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany. 7. Medical Care Center Dresden, Labor Moebius, Dresden, Germany. 8. Duc's Laboratories, Amita Monestry, Mannheim, Germany.
Abstract
BACKGROUND: Compared to blood component safety, the administration of blood may not be as safe as intended. The German Interdisciplinary Task Force for Clinical Hemotherapy (IAKH) specialized registry for administration errors of blood products was chosen for a detailed analysis of reports. METHODS: Voluntarily submitted critical incident reports (n = 138) from 2009 to 2013 were analyzed. RESULTS: Incidents occurred in the operation room (34.1%), in the ICU (25.2%), and in the peripheral ward (18.5%). Procedural steps with errors were administration to the patient (27.2%), indication and blood order (17.1%), patient identification (17.1%), and blood sample withdrawal and tube labeling (18.0%). Bedside testing (BST) of blood groups avoided errors in only 2.6%. Associated factors were routine work conditions (66%), communication error (36%), emergency case (26%), night or weekend team (39%), untrained personnel (19%). Recommendations addressed process and quality (n = 479) as well as structure quality (n = 314). In 189 instances, an IT solution would have helped to avoid the error. CONCLUSIONS: The administration process is prone to errors at the patient assessment for the need to transfuse and the application of blood products to patients. BST is only detecting a minority of handling errors. According to the expert recommendations for practice improvement, the potential to improve transfusion safety by a technical solution is considerable.
BACKGROUND: Compared to blood component safety, the administration of blood may not be as safe as intended. The German Interdisciplinary Task Force for Clinical Hemotherapy (IAKH) specialized registry for administration errors of blood products was chosen for a detailed analysis of reports. METHODS: Voluntarily submitted critical incident reports (n = 138) from 2009 to 2013 were analyzed. RESULTS: Incidents occurred in the operation room (34.1%), in the ICU (25.2%), and in the peripheral ward (18.5%). Procedural steps with errors were administration to the patient (27.2%), indication and blood order (17.1%), patient identification (17.1%), and blood sample withdrawal and tube labeling (18.0%). Bedside testing (BST) of blood groups avoided errors in only 2.6%. Associated factors were routine work conditions (66%), communication error (36%), emergency case (26%), night or weekend team (39%), untrained personnel (19%). Recommendations addressed process and quality (n = 479) as well as structure quality (n = 314). In 189 instances, an IT solution would have helped to avoid the error. CONCLUSIONS: The administration process is prone to errors at the patient assessment for the need to transfuse and the application of blood products to patients. BST is only detecting a minority of handling errors. According to the expert recommendations for practice improvement, the potential to improve transfusion safety by a technical solution is considerable.
Entities:
Keywords:
Administration safety; Confusion; Critical incidents; Error; Error reporting; Hemotherapy; Right patient; Right tube; Transfusion safety
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