Document Detail


Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors.
MedLine Citation:
PMID:  23541010     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
OBJECTIVE: To 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 METHODS: Our 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.
RESULTS: A 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).
CONCLUSION: Institution of a computerized bar code-based blood identification system was associated with a large increase in discovered near-miss events.
Authors:
Gregory A Nuttall; John P Abenstein; James R Stubbs; Paula Santrach; Mark H Ereth; Pamela M Johnson; Emily Douglas; William C Oliver
Publication Detail:
Type:  Evaluation Studies; Journal Article; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  Mayo Clinic proceedings     Volume:  88     ISSN:  1942-5546     ISO Abbreviation:  Mayo Clin. Proc.     Publication Date:  2013 Apr 
Date Detail:
Created Date:  2013-04-01     Completed Date:  2013-07-01     Revised Date:  2013-12-13    
Medline Journal Info:
Nlm Unique ID:  0405543     Medline TA:  Mayo Clin Proc     Country:  England    
Other Details:
Languages:  eng     Pagination:  354-9     Citation Subset:  AIM; IM    
Copyright Information:
Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
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MeSH Terms
Descriptor/Qualifier:
Automatic Data Processing*
Blood Safety / methods*
Blood Transfusion / statistics & numerical data*
Humans
Medical Errors / prevention & control*,  statistics & numerical data
Patient Identification Systems*
Product Labeling*
Program Evaluation
Retrospective Studies

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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