Michael F Murphy1,2, J Jayne Addison1,3, Debbi Poles3, Paula Dhiman2,4, Paula Bolton-Maggs3,5. 1. NHS Blood & Transplant (NHSBT), Watford, UK. 2. Oxford NIHR Biomedical Research Centre, Oxford University Hospitals, University of Oxford, Oxford, UK. 3. Serious Hazards of Transfusion (SHOT) scheme, Manchester, UK. 4. Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK. 5. University of Manchester, Manchester, UK.
Abstract
BACKGROUND: Errors in hospital transfusion may cause wrong (blood) components to be transfused. This study assessed the value of electronic identification systems (EISs) in reducing wrong component transfusions (WCTs). METHODS: UK hospitals reporting to Serious Hazards of Transfusion were invited to complete an electronic survey about transfusion including the use of EISs. Further information was requested for WCTs and near-miss WCTs. RESULTS: A response rate of 93 of 222 (42%) hospitals accounted for 38% of UK blood component issues in 2015 and 2016. Thirty-three of 93 (35%) hospitals employ manual procedures and 16 (17%) use EISs throughout the transfusion process; most of the remainder use EISs for blood collection only. Fifty-seven WCTs were identified in approximately two million blood components. The primary error was at blood draw and sample labeling (3), blood collection (15), and administration (2); the remainder were mostly blood bank errors. No WCTs occurred with blood draw and sample labeling or administration with use of EISs. Three WCTs occurred with EISs for blood collection due to incorrect processes for emergency transfusions of group O blood without any adverse effects. Seventeen WCTs occurred with manual processes; one was an ABO-incompatible red blood cell transfusion resulting in renal impairment. Near-miss WCTs were also more frequent with manual procedures than EISs at blood draw and sample labeling and blood collection. CONCLUSIONS: This is the first multicenter study to demonstrate a lower incidence of WCTs and near-miss WCTs with EISs compared to manual processes, and highlights some limitations of both manual and EIS procedures.
BACKGROUND: Errors in hospital transfusion may cause wrong (blood) components to be transfused. This study assessed the value of electronic identification systems (EISs) in reducing wrong component transfusions (WCTs). METHODS: UK hospitals reporting to Serious Hazards of Transfusion were invited to complete an electronic survey about transfusion including the use of EISs. Further information was requested for WCTs and near-miss WCTs. RESULTS: A response rate of 93 of 222 (42%) hospitals accounted for 38% of UK blood component issues in 2015 and 2016. Thirty-three of 93 (35%) hospitals employ manual procedures and 16 (17%) use EISs throughout the transfusion process; most of the remainder use EISs for blood collection only. Fifty-seven WCTs were identified in approximately two million blood components. The primary error was at blood draw and sample labeling (3), blood collection (15), and administration (2); the remainder were mostly blood bank errors. No WCTs occurred with blood draw and sample labeling or administration with use of EISs. Three WCTs occurred with EISs for blood collection due to incorrect processes for emergency transfusions of group O blood without any adverse effects. Seventeen WCTs occurred with manual processes; one was an ABO-incompatible red blood cell transfusion resulting in renal impairment. Near-miss WCTs were also more frequent with manual procedures than EISs at blood draw and sample labeling and blood collection. CONCLUSIONS: This is the first multicenter study to demonstrate a lower incidence of WCTs and near-miss WCTs with EISs compared to manual processes, and highlights some limitations of both manual and EIS procedures.