Reducing the risk of mistransfusion.
|Article Type:||Letter to the editor|
|Publication:||Name: Archives of Pathology & Laboratory Medicine Publisher: College of American Pathologists Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 College of American Pathologists ISSN: 1543-2165|
|Issue:||Date: Feb, 2009 Source Volume: 133 Source Issue: 2|
To the Editor--We would like to update our experience in reducing
the risk of mistransfusion. (1) In our earlier report, (2) we collected
data on mislabeled blood bank samples, classified by severity and by
location. Overall, the incidence of mislabeling was 0.5%; about
one-third of these events involved miscollected specimens discovered
when an ABO/Rh result on a current specimen did not match the historical
blood type on file, also known as "wrong blood in tube" (WBIT)
samples. Targeting patient care areas contributing to recurring WBITs
with timely feedback led to a decrease in the number of WBIT specimens.
Subsequent to the initial effort, we implemented a 2-signature
requirement for all blood bank samples. The number of WBIT cases has
decreased from an average of 5.8 per quarter to 2.3 per quarter (see
Figure). Although our ultimate goal is to use electronic bar code
specimen labeling at the bedside, which has been demonstrated to reduce
misidentification of clinical laboratory samples, (3) followed by an
electronic blood unit verification system, (4) we are gratified that a
"low-tech" strategy, in conjunction with continued education
among laboratory and nonlaboratory phlebotomists, can reduce the risk of
mistransfusion. We plan to trend our future efforts using statistical
process control tools. (5)
(1.) College of American Pathologists Commission on Laboratory Accreditation, Laboratory Accreditation Program. Transfusion Medicine Checklist. TRM.30575. Revised September 27, 2007. Northfield, IL: College of American Pathologists; 2007.
(2.) Quillen K, Murphy K. Quality improvement to decrease specimen mislabeling in transfusion medicine. Arch Pathol Lab Med. 2006;130(8):1196-1198.
(3.) Hayden RT, Patterson DJ, Jay DW, et al. Computer-assisted bar-coding system significantly reduces clinical laboratory specimen identification errors in a pediatric oncology hospital. J Pediatr. 2008; 152(2):219-224.
(4.) Staves J, Davies A, Kay J, Pearson O, Johnson T, Murphy MF. 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. Transfusion. 2008;48(3): 415-424.
(5.) Dzik WS, Beckman N, Selleng K, et al. Errors in patient specimen collection: application of statistical process control. Transfusion. 2008;48(10): 2143-2151.
The authors have no relevant financial interest in the products or companies described in this article.
KAREN QUILLEN, MD
KATE MURPHY, MT(ASCP), SBB
Department of Laboratory Medicine
Boston University Medical Center
Boston, MA 02118
Number of wrong blood in tube (WBIT) cases per quarter. The 2 interventions included targeted feedback (identifying patient care areas contributing to WBITs) and 2-signature requirement for all blood bank specimens. 2nd Qtr. 7 3rd Qtr. 10 4th Qtr. 13 2006 1st Qtr. 8 2nd Qtr. 4 3rd Qtr. 6 4th Qtr. 4 2007 1st Qtr. 6 2nd Qtr. 7 3rd Qtr. 3 4th Qtr. 1 2008 1st Qtr. 3 2nd Qtr. 2 Note: Table made from line graph.
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