Experience with the medical event reporting system for transfusion medicine (MERS-TM) at three hospitals.

BACKGROUND: The MERS-TM assists hospital transfusion services to identify, analyze, and correct system events relating to the delivery of blood to patients. METHODS: The MERS-TM system was used from February of 1999 to December 2002. All reported near-miss and actual events were recorded and analyzed. RESULTS: During these 47 months, 4670 events were reported by the transfusion service. Of these events, 94% were classified as a near-miss event and 93% were detected before the blood product was administered. No ABO-incompatible transfusions were detected despite transfusion of 50,137 units of red blood cells. High severity events with the potential for patient harm accounted for 241 (5%) of the 4670 events. Nursing related events accounted for 188 (78%) of the high severity events. In one out of 4430 (0.023%) samples tested, a high severity sample-testing event was detected. In one out of 1550 (0.06%) samples collected, a high severity sample-collection event was detected. CONCLUSION: An event reporting system is essential if one is to determine where and how often events are occurring within the transfusion process.     

Improvement in transfusion safety using a specially designed transfusion wristband

Fatal haemolytic transfusion reaction due to ABO incompatibility occurs mainly as a result of clerical error. A blood sample drawn from the wrong patient and labelled as another patient's will not be detected by the blood bank unless there is a previous ABO grouping result. We report here the detection of such clerical error by the use of a specially designed transfusion wristband. The wristband has the following special features: (i) once attached, it cannot be removed except by cutting; (ii) it has a pocket containing a transfusion label; (iii) a unique transfusion barcode is printed on each transfusion label and the corresponding wristband simultaneously by computer technology; (iv) a transfusion label removed from the wristband after attachment to the patient has a characteristic tear-mark distinguishing it from one removed prior to attachment. The blood bank only accepted those specimens bearing the tear-marked transfusion labels. All blood units for this patient were labelled with this unique transfusion code together with the patient's details. The nurses counter-checked the transfusion code on the blood units against the transfusion code on the patient's transfusion wristband prior to transfusion. If the blood sample for compatibility testing was drawn from the 'wrong' patient, the intended patient either did not carry a wristband or the transfusion codes did not match at all. Pretransfusion compatibility tests were performed on 2189 patient samples using this procedure. It was well accepted by both ward and blood bank staff. Two potential mismatched transfusions were avoided. These two clerical errors would not have been detected because neither patient had previous ABO grouping results.     

A report of 104 transfusion errors in New York State

In New York State, significant incidents involving the collection, processing, or transfusion of blood must be reported. Incident reports received over a 22-month period involving transfusion of blood to other than the intended recipient or release of blood of an incorrect group were analyzed. Among 1,784,600 transfusions of red cell components; there were 92 cases of erroneous transfusion that met study criteria (1/19,000). There were 54 ABO-incompatible transfusions (1/33,000); three of these (1/600,000) were fatal. Correction for underreporting of ABO-compatible errors resulted in an estimate of 1 per 12,000 as the true risk of transfusion error. National application of New York State data results in an estimate of 800 to 900 projected red cell-associated errors in the United States annually. The majority of reported errors occurred outside of the blood bank (43% resulted solely from failure to identify the patient and/or unit prior to transfusion and 11% resulted from phlebotomist error), while the blood bank was responsible for 25 percent of errors and contributed, with another hospital service, to 17 percent. The risk of transfusion of ABO-incompatible blood remains significant, and additional precautions to minimize the likelihood of such events should be considered.     

Prospective RBC phenotype matching in a stroke-prevention trial in sickle cell anemia: a multicenter transfusion trial

BACKGROUND: Most sickle cell anemia patients undergo transfusion therapy to prevent complications. The Stroke Prevention Trial in Sickle Cell Anemia showed that transfusion therapy is effective in the primary prevention of stroke. Despite its efficacy, transfusion therapy is limited by alloimmunization. The purpose of this study was to determine if a multicenter trial could implement a transfusion program utilizing phenotypically matched blood to reduce alloimmunization. STUDY DESIGN AND METHODS: One hundred thirty children underwent RBC phenotyping and antibody screening with review of blood bank records. The protocol required use of WBC-reduced RBCs, which were matched for E, C, and Kell. Monthly alloantibody testing and review of transfusion forms were performed to determine compliance and the occurrence of any adverse events. RESULTS: Patient RBCs expressed a low frequency of Kell (2%), E (20%), and C (25%) antigens. Sixty-one patients received 1830 units. Ninety-seven percent of all units were WBC reduced. Only 29 units were inadvertently not matched for E, C, and Kell. Five patients (8%) developed a clinically significant alloantibody. Four developed a single antibody to E or Kell. Three patients (5%) developed a warm autoantibody. There were 11 transfusion reactions and 8 transfusion-associated events. Transfusion reactions included 6 febrile reactions (0.33%/unit), 3 allergic (0.16%/unit), and 2 hemolytic (0.11%/unit). Associated events included 4 episodes of hypertension (0.22%/unit), 3 crises (0.16%/unit), and 1 transient ischemic attack (0.05%/unit). CONCLUSION: This is the first multicenter study to show that extended RBC phenotyping can be implemented nationwide. Compared to studies, the alloimmunization rate dropped from 3 percent to 0.5 percent per unit, and hemolytic transfusion reactions dropped by 90 percent. It is recommended that all transfused sickle cell anemia patients be antigen matched for E, C, and Kell. Patients should be closely monitored during transfusions to avoid preventable risks.     

Computerized Bar Code–Based Blood Identification Systems and Near-Miss Transfusion Episodes and Transfusion Errors

ObjectiveTo determine whether the use of a computerized bar code–based blood identification system resulted in a reduction in transfusion errors or near-miss transfusion episodes.Patients and MethodsOur institution instituted a computerized bar code–based blood identification system in October 2006. After institutional review board approval, we performed a retrospective study of transfusion errors from January 1, 2002, through December 31, 2005, and from January 1, 2007, through December 31, 2010.ResultsA total of 388,837 U were transfused during the 2002-2005 period. There were 6 misidentification episodes of a blood product being transfused to the wrong patient during that period (incidence of 1 in 64,806 U or 1.5 per 100,000 transfusions; 95% CI, 0.6-3.3 per 100,000 transfusions). There was 1 reported near-miss transfusion episode (incidence of 0.3 per 100,000 transfusions; 95% CI, <0.1-1.4 per 100,000 transfusions). A total of 304,136 U were transfused during the 2007-2010 period. There was 1 misidentification episode of a blood product transfused to the wrong patient during that period when the blood bag and patient’s armband were scanned after starting to transfuse the unit (incidence of 1 in 304,136 U or 0.3 per 100,000 transfusions; 95% CI, <0.1-1.8 per 100,000 transfusions; P=.14). There were 34 reported near-miss transfusion errors (incidence of 11.2 per 100,000 transfusions; 95% CI, 7.7-15.6 per 100,000 transfusions; P<.001).ConclusionInstitution of a computerized bar code–based blood identification system was associated with a large increase in discovered near-miss events.     

A fully automated blood typing system for hospital transfusion services. ABS2000 Study Group

BACKGROUND: The results of routine blood bank testing by a fully automated blood typing system (ABS2000) were compared with those obtained by standard manual methods in six hospital transfusion services. STUDY DESIGN AND METHODS: The ABS2000 system uses microtiter plates for determining ABO and D types, solid-phase red cell adherence (SPRCA) assays for antibody detection, and modified SPRCA plates for IgG crossmatches. The transfusion services used their standard manual test tube methods. RESULTS: Of 3779 donors' samples tested for ABO types (red cell typings only), 3.0 percent could not be interpreted by the ABS2000 system's neural network, because of clots, hemolysis, or lipemic samples. The results for ABO types were concordant for 99.8 percent of the remaining samples. Of 3779 donors' samples tested for D types, the results were concordant for 98.7 percent. Of 7580 patients' samples tested for ABO types (red cell and plasma typings), 5.8 percent could not be interpreted by the ABS2000 system. There was 100-percent concordance of ABO typing results for the remaining 7140 samples. There was 99. 7-percent concordance of results for patients' D types. The results of 96.7 percent of antibody detection tests and 98.8 percent of crossmatches were concordant. Neither method failed to detect a serologically incompatible crossmatch that was associated with a specific, clinically significant alloantibody. The ABS2000 system performed 45 confirmatory donor ABO and D types in 115 minutes, 22 antibody detection tests in 116 minutes, 16 patients' ABO/D types in 149 minutes, and 40 crossmatches in 140 minutes. CONCLUSION: The ABS2000 blood typing system automates routine blood bank tests with accuracy comparable to that of hospital transfusion services' standard manual methods.     

Error management of emergency transfusions: a surveillance system to detect safety risks in day to day practice.

Acute hemolysis due to AB0-incompatibility caused by transfusion of red blood cell concentrates (RBCC) to the wrong recipient is one of the major causes of transfusion-related death. As part of our policy to improve quality and safety in emergency transfusion, we have developed a standardized surveillance system for supplying RBCC in emergency situations. This surveillance system involves the implementation of a standardized set of basic data transmitted from the requesting unit to the blood bank by phone and a scoring system to check for compliance with guidelines and errors in daily routines. Communication deficiencies and delayed pretransfusion sampling were the most common errors.     

Blood transfusion costs by diagnosis-related groups in 60 university hospitals in 1995

BACKGROUND: Transfusion services are frequently challenged to initiate efforts to reduce blood transfusion costs. One approach is to analyze blood transfusion costs for individual medical and surgical Diagnosis-Related Groups (DRGs). Rank ordering of DRGs by transfusion costs and interinstitutional comparisons of these costs may lead to the selection of DRGs for further analysis of the process of blood transfusion. STUDY DESIGN AND METHODS: Common DRGs (n = 486) that were related to discharges in 1995 were analyzed from 60 university hospital members of the University HealthSystems Consortium (UHC). Cost data were tabulated by using cost-to-charge ratios reflecting all aspects of blood transfusion-related costs of participating institutions. RESULTS: Of these 486 DRGs, 471 had identifiable mean blood costs, and 34 had median blood costs, mostly for surgical conditions. Transfusion costs represented a small proportion (< or = 1%) of total hospitalization costs for most DRGS: Nonetheless, millions of dollars were spent on blood transfusion, and for the most expensive DRGs, the costs ranged from 5.0 to 8.6 percent of total hospitalization costs. Transfusion costs are more variable for the DRGs with the lowest transfusion costs than for those with the highest transfusion costs. CONCLUSION: Members of the UHC may utilize such analyses to identify surgical or medical diagnoses with transfusion costs at variance with the group norm. These DRGs could then be targeted for further evaluation of components contributing to high costs, for possible alterations in physician or clinical laboratory practices. Considering those conditions with the highest cumulative transfusion costs (e.g., BMT, liver transplant, acute leukemia, and cardiothoracic procedures), changes in transfusion practices that affect these particular patient categories may have a significant impact on global blood transfusion costs.     

Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors.

BACKGROUND: To transfuse blood products safely, health care workers must accurately identify patients, blood samples, and the blood components. A comprehensive bar code-based computerized tracking system was developed and implemented to identify and prevent transfusion errors. STUDY DESIGN AND METHODS: A data network, wireless devices, and bar-coded labels were pilot tested before the system was introduced hospitalwide. The system provided a complete audit trail for all transactions. Data from before and after implementation were analyzed. RESULTS: Incident reports decreased from a mean of 41.5 reports per month in the 6 months before the system was implemented to a mean of 7.2 reports per month after implementation. The blood sample rejection rate decreased from 1.82 percent to a mean of 0.17 percent after implementation. Errors detected by the new system were sorted into misscans, skipped steps, wrong steps, and prevented identification errors (PIEs). Misscans and skipped steps were the most common errors in the first 10 months after implementation. During the final transfusion step, PIEs occurred at the rate of about one per month and scans were omitted approximately 1 percent of the time. Therefore, it is estimated that mistransfusions could occur about once every 100 months on average with the new system. CONCLUSIONS: The bar code-based computerized tracking system detected and prevented identification and matching errors, thereby reducing the proportion of blood samples rejected and increasing patient safety.     

Electronic remote blood issue: a combination of remote blood issue with a system for end-to-end electronic control of transfusion to provide a "total solution" for a safe and timely hospital blood transfusion service

BACKGROUND: The rapid provision of red cell (RBC) units to patients needing blood urgently is an issue of major importance in transfusion medicine. The development of electronic issue (sometimes termed "electronic crossmatch") has facilitated rapid provision of RBC units by avoidance of the serologic crossmatch in eligible patients. A further development is the issue of blood under electronic control at blood refrigerator remote from the blood bank. STUDY DESIGN AND METHODS: This study evaluated a system for electronic remote blood issue (ERBI) developed as an enhancement of a system for end-to-end electronic control of hospital transfusion. Practice was evaluated before and after its introduction in cardiac surgery. RESULTS: Before the implementation of ERBI, the median time to deliver urgently required RBC units to the patient was 24 minutes. After its implementation, RBC units were obtained from the nearby blood refrigerator in a median time of 59 seconds (range, 30 sec to 2 min). The study also found that unused requests were reduced significantly from 42 to 20 percent, the number of RBC units issued reduced by 52 percent, the number of issued units that were transfused increased from 40 to 62 percent, and there was a significant reduction in the workload of both blood bank and clinical staff. CONCLUSIONS: This study evaluated a combination of remote blood issue with an end-to-end electronically controlled hospital transfusion process, ERBI. ERBI reduced the time to make blood available for surgical patients and improved the efficiency of hospital transfusion.     

Alloimmunization after blood transfusion in patients with hematologic and oncologic diseases

BACKGROUND: Because of intensive marrow depression and improved survival, patients with hematologic and oncologic malignancies are dependent on transfusion for a longer period. It has been advocated that these patients should receive blood that is matched for blood group antigens other than ABO and D. A retrospective study was performed on the rate of alloimmunization against red cell antigens in 564 patients with malignant hematologic diseases over a period of 10 years. STUDY DESIGN AND METHODS: Records of transfusion and immunohematologic studies of all patients (n = 1066) with malignant myeloproliferative and lymphoproliferative diseases diagnosed between 1987 and 1996 at one hospital were collected from the hospital computer blood bank files. Transfusions were correlated with antibody formation. Factors affecting this correlation were analyzed. RESULTS: Seventy-one antibodies were found in 51 patients. The overall immunization rate was 9.0 percent. Fifty percent of antibodies were formed after 13 units had been transfused. Once a patient had formed an antibody, the probability of additional antibodies increased 3.3-fold. Anti-c, anti-E, and anti-K composed the majority of antibodies found. Four patients formed Rh system antibodies after incompatible platelet transfusions. Patients who underwent intensive chemotherapy formed antibodies at a much lower rate than other patients. More than 40 percent of antibodies became undetectable after the first detection. No difficulty was encountered in finding compatible blood for these patients. CONCLUSIONS: Antibody formation in hematologic malignancies is comparable to that in other diseases requiring multiple blood transfusions. Extensive antigen matching before transfusion of patients with hematologic and oncologic malignancies is not necessary and leads to increased costs.     

Improving transfusion safety: implementation of a comprehensive computerized bar code–based tracking system for detecting and preventing errors

BACKGROUND: To transfuse blood products safely, health care workers must accurately identify patients, blood samples, and the blood components. A comprehensive bar code–based computerized tracking system was developed and implemented to identify and prevent transfusion errors.
STUDY DESIGN AND METHODS: A data network, wireless devices, and bar-coded labels were pilot tested before the system was introduced hospitalwide. The system provided a complete audit trail for all transactions. Data from before and after implementation were analyzed.
RESULTS: Incident reports decreased from a mean of 41.5 reports per month in the 6 months before the system was implemented to a mean of 7.2 reports per month after implementation. The blood sample rejection rate decreased from 1.82 percent to a mean of 0.17 percent after implementation. Errors detected by the new system were sorted into misscans, skipped steps, wrong steps, and prevented identification errors (PIEs). Misscans and skipped steps were the most common errors in the first 10 months after implementation. During the final transfusion step, PIEs occurred at the rate of about one per month and scans were omitted approximately 1 percent of the time. Therefore, it is estimated that mistransfusions could occur about once every 100 months on average with the new system.
CONCLUSIONS: The bar code–based computerized tracking system detected and prevented identification and matching errors, thereby reducing the proportion of blood samples rejected and increasing patient safety.     

Blood bank on-call physician's experiences at a large university medical center

BACKGROUND: The responsibilities of the blood bank on-call physician (blood bank physician from here on) encompass many aspects of transfusion medicine and physician education. This physician is available 24 hours a day to address any issues concerning the collection and transfusion of blood and blood components. The purpose of this study was to identify and categorize the issues that may confront a blood bank physician. STUDY DESIGN AND METHODS: Each call received over a 4-month period was logged and the resolution documented. The calls were grouped into five categories: donor issues, therapeutic procedure issues, patient issues, physician education issues, and requests for blood components not meeting previously defined transfusion guidelines. RESULTS: The blood bank physician received 224 calls during the study period. To resolve each issue, an additional 1 to 14 telephone calls were needed to gather further information. Number of calls by category were donor issues, 20 (8.9%); therapeutic procedure issues, 9 (4.0%); patient issues, 4 (1.8%); physician education issues, 33 (14.7%); and requests for blood components not meeting previously defined transfusion guidelines, 158 (70.6%). Requests for blood components were denied in 39.8 percent of the cases not meeting guidelines. Other forms of therapy were warranted in 20.9 percent of the cases. CONCLUSION: This study revealed that 85.3 percent of the calls referred to the blood bank physician related to physician education and the appropriateness of blood component orders. These results emphasize the need for ongoing education of medical staff in transfusion medicine issues.     

Blood transfusion in a random sample of hospitals in France

BACKGROUND: Representative information on blood use is scarce. A large-scale study of blood recipients and blood use in France was conducted. STUDY DESIGN AND METHODS: Based on a random sampling, this study was carried out in teaching and other hospitals between March and December 1997. In each hospital, a patient was included if he or she received an allogeneic or an autologous transfusion during the observation period for that hospital. For each recipient, product and patient characteristics for 24 hours after inclusion were collected. RESULTS: From the 175 hospitals that had given a transfusion to at least one patient during the observation period, 3206 patients were included. Most transfusion recipients (57%) were over 65 years old; 42 percent were in teaching hospitals and 53 percent in medical wards. Among the 3044 adults, 91 percent received an allogeneic transfusion. Fifty-three percent of allogeneic units were WBC reduced. The indications most frequently reported for allogeneic transfusion were neoplasms (48%) and those for autologous transfusion were disorders of musculoskeletal (63%) or circulatory (15%) systems. The patients in nonteaching hospitals were more often transfused during surgery and were more likely to be aged and to have a musculoskeletal disorder than were patients in teaching hospitals. CONCLUSION: General collection of such data, within a system of traceability, could provide relevant denominators from which to interpret adverse-reaction data.     

Analysis of ABO discrepancies occurring in 35 French hospitals

BACKGROUND: The risk of immunohemolytic reaction owing to ABO-mismatched mistransfusion is 100 to 1000 times higher than the risk of viral infection. Like analysis of incident reports, evaluation of near-miss events can provide useful insight into hazardous situations for mis-matched blood transfusion. The aim of this prospective study was to assess the incidence and root causes of all ABO discrepancies, detected by a central hematology laboratory, in blood samples referred from 35 district hospitals. STUDY DESIGN AND METHODS: ABO discrepancies were detected by comparing either two current blood specimens or a current and historical specimen collected over a 5-year study period. Discrepancies were investigated by retyping new samples, checking sample identification, and reviewing previous hospital records. RESULTS: A total of 118 ABO discrepancies were discovered in a series of 407,769 tests carried out during the study period. The incidence of ABO discrepancies was 1 per 3,400. This figure was 10 times higher than the incidence of ABO-mismatched transfusions. Most of these ABO discrepancies were due to phlebotomy errors, that is, collection from wrong patient. The second most common cause involved clerical errors during patient registration or identification. CONCLUSION: ABO discrepancies can result from errors made not only by the medical staff during phlebotomy but also to by the clerical staff during registration and identification. These findings emphasize the need to standardize data transmission between health care personnel.     

Near-miss errors in laboratory blood test requests by interns

BACKGROUND: Human errors have proven to be one of the most formidable patient care challenges in acute hospital setting. AIM: To evaluate the at-risk period for near-miss errors in laboratory blood test requests, in an acute medical hospital. DESIGN: Hospital-based retrospective analysis. METHODS: We reviewed the database of voluntary reports for near-miss errors for laboratory blood test requests by 104 medical residents in their first postgraduate year (interns), over a 2-year period (October 2002 to September 2004). To identify patterns and causal factors we analysed the reports with respect to months of working experience, work hours, and work shifts of an extended duration. RESULTS: There were 52 near-miss events among patients cared for by the medical service (20 male patients, 32 females, mean age 72.6 +/- 9.7 years). The overall incidence of near-miss events when interns practiced during the first month of training vs. subsequent months was 1.6 (95%CI 0.77-2.9) vs. 0.6 (95%CI 0.44-0.83) cases per 100 intern-days at risk. The odds ratio for a near-miss event during the first month of intern training vs. subsequent months was 2.64 (95%CI 1.29-5.38). With respect to the interns' on-call shift schedule, one half of the near-miss episodes occurred during an intern's on-call days and another half of them during an extended on-call shift; none of the events occurred during a standard working shift. These events peaked in frequency when on-call interns had worked for 12-20 h. DISCUSSION: The first month of internship represents an error-prone period. The best interventions to reduce near-miss errors by recently graduated medical interns should be the subject of further research.     

Transfusion-transmitted bacterial infectionin the United States, 1998 through 2000

BACKGROUND: Bacterial contamination of blood components can result in transfusion-transmitted infection, but the risk is not established. STUDY DESIGN AND METHODS: Suspected cases of transfusion-transmitted bacteremia were reported to the CDC by participating blood collection facilities and transfusion services affiliated with the American Red Cross, AABB, or Department of Defense blood programs from 1998 through 2000. A case was defined as any transfusion reaction meeting clinical criteria in which the same organism species was cultured from a blood component and from recipient blood, with the organism pair confirmed as identical by molecular typing. RESULTS: There were 34 cases and 9 deaths. The rate of transfusion-transmitted bacteremia (in events/million units) was 9.98 for single-donor platelets, 10.64 for pooled platelets, and 0.21 for RBC units; for fatal reactions, the rates were 1.94, 2.22, and 0.13, respectively. Patients at greatest risk for death received components containing gram-negative organisms (OR, 7.5; 95% CI, 1.3-64.2; p = 0.009). CONCLUSION: Bacterial contamination of blood is an important cause of transfusion-transmitted infection; infection risk from platelet transfusion is higher compared with that from RBCs, and, overall, the risk of infection from bacterial contamination now may exceed that from viral agents. Recipients of components containing gram-negative organisms are at highest risk for transfusion-related death. The results of this study may help direct efforts to improve transfusion-related patient safety.     

Providing feedback to users on unacceptable practice in the delivery of a hospital transfusion service--a pilot study

The Serious Hazards of Transfusion Scheme's (SHOT) annual report continues to emphasize the importance of investigating serious transfusion errors. It is now recognized that lessons can also be learnt from near-miss events as these occur more frequently than serious errors in transfusion. One of the key features in developing a culture that can promote safety in relation to transfusion is providing feedback to staff on what is acceptable and unacceptable practice. We have developed a scoring system based on the number of serious errors and near misses that occur in the transfusion service to provide feedback to staff on their performance in relation to the administration of blood components and blood products. This was developed as part of an ongoing error logging system that we have previously described. The implementation of this feedback has resulted in an increased awareness within our organization of safety issues in relation to transfusion, and has highlighted the importance of the detection and correction of less serious errors.     

Documenting a transfusion: how well is it done?

BACKGROUND: Current practice in transfusion medicine promotes clear documentation of transfusion-related events including the fact that the patient has been informed of the related risks and benefits. STUDY DESIGN AND METHODS: A retrospective review of 1005 patient charts was carried out to determine documentation. RESULTS: Most patients were from general surgery (10.8%) and cardiac surgery (14.1%). In 75 percent of cases the physician had not documented that any discussion had occurred regarding the risks and/or benefits or alternatives. Only 12 percent of charts included information that the patient was subsequently told what blood components were given to them. The discharge summary recorded transfusion information in 32.1 percent of cases whereas the consult note had this information in 26.3 percent. Chart records matched the transfusion medicine records in 60.6 percent of cases. The most common error was in the blood unit identification number. CONCLUSIONS: While accepted in theory, the practice of documenting patient information on transfusion is not well done.