New technology for transfusion safety.
Hemovigilance programs from around the world document that the greatest risk to recipients of blood transfusion is human error, resulting in transfusion of the incorrect blood component. Errors in transfusion care have strong parallels with errors in medication administration. Errors often result from 'lapse' or 'slip' mistakes in which details of patient identification are overlooked. Three areas of transfusion are focal points for improved care: the labelling of the patient's pre-transfusion sample, the decision to transfuse and the final bedside check designed to prevent mis-transfusion. Both barcodes and radio-frequency identification technology, each ideally suited to matching alpha-numeric identifiers, are being implemented in order to improve performance sample labelling and the bedside check. The decision to transfuse should ultimately be enhanced through the use of nanotechnology sensors, computerised order entry and decision support systems. Obstacles to the deployment of new technology include resistance to change, confusion regarding the best technology, and uncertainty regarding the return-on-investment. By focusing on overall transfusion safety, deploying validated systems appropriate for both medication and blood administration, thoughtful integration of technology into bedside practice and demonstration of improved performance, the application of new technologies will improve care for patients in need of transfusion therapy.
Dzik
Walter H
WH
Massachusetts General Hospital, Boston, MA 02114, USA. sdzik@partners.org
D001788:Blood Grouping and Crossmatching; D001800:Blood Specimen Collection / Q000592:standards; D001803:Blood Transfusion / Q000592:standards*; D016303:Clinical Pharmacy Information Systems; D006801:Humans; D019300:Medical Errors; D010355:Patient Identification Systems; D018579:Patient Selection; D019095:Point-of-Care Systems; D017751:Safety Management / Q000379:methods; D065227:Transfusion Reaction