Blood product transfusion errors continue to pose a significant risk to patients nationwide. Most blood product transfusion errors are the result of incorrect identification of the patient, blood samples for type and cross match, or blood components. To increase the safety of patients undergoing transfusions and reduce the risk of adverse events, it is necessary to ensure that patients, blood samples, and blood products are accurately identified throughout the entire transfusion process.
The specific aim of this project is to track and execute identity checks when blood samples are collected, transported, and analyzed, and when blood products are released from the Blood Bank and administered to patients. These identity checks would be facilitated by providing the frontline personnel with handheld wireless barcode devices at the point of care. Barcodes attached to blood products and patients will be scanned and the resulting information will be fed automatically into a new online """"""""check"""""""" application that will provide immediate notification of any mismatches. At each critical checkpoint in the process of blood transfusion, staff members will utilize the new application, thereby ensuring that all transactions will be electronically logged and monitored. The project will be implemented in stages, with problems being addressed in pilot tests. The efficacy of the project will be assessed by comparing the proportion of mislabeled blood specimens, mislabeled blood products, and misidentified patients before and after the implementation of the project. The chi-square test of two proportions will be used to assess whether changes in these proportions are significant. Changes in the types of transfusion errors and in the time required for each step of the transfusion process will be tracked to ensure that the intervention was successful. This project will also create the information systems technology necessary for numerous other patient safety efforts. Thus, this project will maximize the benefit from the resources invested. In addition, to date there are no studies in the literature that document the efficacy of barcoding technology for improving patient safety. This project was designed to fill that gap.
