[Protection against mismatched transfusion during operation double check system].
BACKGROUND
Three mistakes in recording blood types in the operation sheets occurred at the operating room of Iwamizawa Municipal General Hospital in 3 months (June-August, 2004).


METHODS
From these accidents, anesthesiologists and the staff improved the blood typing checking system to prevent mismatched transfusion during operation as follows; 1. The blood typing must be done at our out-patient's department, while the blood group compatibility test must be done at our inpatient's department. 2. We must describe the results of blood typing on the anesthesia application form using red colored pen. More than two medical staffs must confirm it. 3. Before anesthesia, the anesthesiologist and the nurse should confirm the blood type in loud voice. After that, the nurse must mention blood typing on white board using a red colored pen. 4. Just before transfusion, the anesthesiologist and the nurse should confirm the blood group typing of the patient, that of the preserved blood, and the number of the blood group's compatibility test in loud voice.


RESULTS
From September, 2004 to March, 2005 no accident of blood typing mistake occurred in our hospital.


CONCLUSIONS
Double check system of blood types in surgical patients would be useful in protection against mismatched transfusion during operation.
Yasukawa
Ken-ichi
K
Department of Anesthesia, Iwamizawa Municipal General Hospital, Iwamizawa 068-8555.
Yasukawa
Masako
M
Niibuchi
Kozue
K
Homma
Yasuyuki
Y
D001787:Blood Group Incompatibility / Q000517:prevention & control*; D001788:Blood Grouping and Crossmatching; D001803:Blood Transfusion; D006801:Humans; D012308:Risk Management / Q000379:methods*