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.
Lau
F Y
FY
Department of Medicine and Therapeutics, Chinese University of Hong Kong, China.
Wong
R
R
Chui
C H
CH
Ng
E
E
Cheng
G
G
D001771:Blood Banks / Q000458:organization & administration*; D001787:Blood Group Incompatibility / Q000517:prevention & control*; D001788:Blood Grouping and Crossmatching; D001803:Blood Transfusion / Q000295:instrumentation; D004867:Equipment Design; D004865:Equipment and Supplies, Hospital; D005069:Evaluation Studies as Topic; D005568:Forms and Records Control; D006753:Hospital Records; D006801:Humans; D010355:Patient Identification Systems; D018962:Phlebotomy; D012449:Safety; D013048:Specimen Handling / Q000295:instrumentation*