Bar code technology improves positive patient identification and transfusion safety.
As a result of human error, an estimated 1 in 12,000 blood transfusions is given to the wrong patient. The cause of nearly all of these errors is failure of hospital personnel to identify positively intended transfusion recipients, their blood samples for cross-matching, or their correct blood components. We describe our experience using a point-of-care bar code transfusion safety system that links patients' bar-coded wristbands, with bar-coded labels on blood sample tubes, blood component bags, and nurses' identification badges. The result was 100 % accuracy of matching patients, their blood samples, and components for transfusions. For verifying information before starting blood transfusions, nurses preferred bar code "double checks" to conventional visual "double checks" by a second nurse. Methods are needed to reinforce nurses' proficiency with technological approaches to transfusion safety, such as software-driven bar code scanning, in situations where transfusions are administered infrequently.
Sandler
S G
SG
Departments of Pathology, Laboratory Medicine, and Nursing Services, Georgetown University Hospital, Washington, DC 20007, USA. sandlerg@gunet.georgetown.edu
Langeberg
A
A
Dohnalek
L
L
D001771:Blood Banks; D001803:Blood Transfusion; D001330:Electronic Data Processing; D006801:Humans; D007318:Inservice Training / Q000458:organization & administration; D019300:Medical Errors / Q000517:prevention & control*; D009741:Nursing Staff, Hospital / Q000193:education; D010355:Patient Identification Systems