Blood transfusions have the power to help save the lives of patients who have had a massive trauma, are undergoing a major surgery, or are facing an illness that affects their plasma levels. While transfusions can significantly improve patient health or sustain life, just one simple error in the process can lead to serious injury or even result in patient death.
TRANSFUSION ERRORS ARE A CAUSE FOR CONCERN
- The FDA estimates 414 blood transfusion errors occur each year, and that two-thirds of these errors are associated with incorrect blood recipient identification occurring at the patient’s bedside.
- Patient death or disability associated with incompatible blood is one of the Centers for Medicare & Medicaid Services’ Hospital-Acquired Conditions and is listed as one of the National Quality Forum’s Serious Reportable Events.
- Blood component transfusions to non-designated recipients occur in about 1 of 10,000 events, according to a 2010 blood transfusion study conducted by the Pennsylvania Patient Safety Advisory.
THE JOINT COMMISSION RULES IN ON ELIMINATING TRANSFUSION ERRORS
To help reduce the amount of transfusion errors related to patient misidentification, the Joint Commission has issued the National Patient Safety Goal 01.03.01, “Eliminate transfusion errors related to patient misidentification.” The Elements of Performance for NPSG.01.03.01 requires caregivers to perform a series of steps before initiating a blood or blood component transfusion.
• Match the blood or blood component to the order
• Match the patient to the blood or blood component
• Use a two-person verification process or a one-person verification process accompanied by automated identification technology, such as bar coding.
By using a bar coding system, hospitals are only required to have one person verify the patient ID information instead of two. One person verification improves workflow efficiency; reduces labor costs; and saves caregiver time that can be devoted instead to patient care.
WHY PATIENT MISIDENTIFICATION ERRORS FOR BLOOD TRANSFUSIONS HAPPEN
The FDA states that a bar coding system for blood administration can reduce errors by as much as 90%. While many healthcare facilities now have a bar coding system in place, fatal errors are still being made, according to a 2012 study by Mayo Clinic. Some of the reasons for errors in transfusion include:
• Incorrect bar codes are scanned (bar codes is scanned on patient chart or transfusion order and not on patient wristband)
• Nurse was not required to show proof that patient was scanned immediately prior to transfusion
• Nurse performed a workaround and did not abide by protocol.
A SIMPLE SOLUTION TO HELP PREVENT PATIENT MISIDENTIFICATION ERRORS
Point-of-care, bar coding applications are being integrated with blood product administration protocol to combine patient identification, medication, and product verification into a seamless workflow.
For hospitals using the Cerner Bridge Transfusion Administration, bar code blood band patient ID wristbands are now available that feature special permanent bar codes that must be scanned by a transfusionist as part of the system’s workflow. The permanent bar code ID contains an embedded prefix and suffix code when scanned; ensuring staff verified the patient at bedside. If the correct bar code is not scanned, an on-screen message populates in the system, alerting the caregiver.
A blood transfusion administration workflow program, such as the Cerner Bridge Transfusion Administration system, helps prevent workarounds or shortcuts by caregivers, to reduce the risk of transfusion errors caused by patient misidentification. Using this type of system not only improves patient safety, but also protects caregivers from making preventable mistakes that can lead to adverse events such as patient morbidity or mortality.