title: Prevention of bedside errors in transfusion medicine (PROBE-TM) study: a cluster-randomized, matched-paired clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check.
abstract: BACKGROUND
  Transfusion of the incorrect blood component is a frequent serious incident associated with transfusion and often involves misidentification of the patient and/or the unit of blood. The objective of this study was to assess the effect of a simple intervention designed to improve performance of the bedside check and to observe the durability of any effect. The intervention was a tag on blood bags reminding staff to check the patient's wristband. The tag was positioned in such a way that the transfusionist was required to remove the tag to spike the unit.
  
  
  METHODS
  The intervention was tested in a multicenter cluster-randomized controlled trial incorporating short-term and long-term follow-up periods. The primary endpoint was the proportion of patients transfused with red cell units for whom the key elements of the bedside check were all correctly completed.
  
  
  RESULTS
  Fifteen matched-paired clinical areas at 12 participating hospitals in six countries were included in the trial. Combining data from all participating hospitals, the bedside check was correctly performed in 37 percent of transfusions during the baseline audit period. There was no evidence of a favorable effect of the intervention immediately after its introduction (pooled odds ratio, 1.09; 95% confidence interval, 0.54-2.17). There was similarly no evidence of a favorable effect after continued use of the intervention for an additional 8 weeks.
  
  
  CONCLUSIONS
  A simple intervention in the form of a barrier warning label on blood bags reminding staff to check the patient's wristband failed to improve bedside transfusion practice. The robust study design developed for this study could be applied to investigate other interventions to improve the safety of bedside transfusion practice.
authors.affiliation: National Blood Service, John Radcliffe Hospital, Oxford, UK. mike.murphy@nbs.nhs.uk
authors.forename: Michael F
authors.initials: MF
authors.lastname: Murphy
authors.forename: Angela C
authors.initials: AC
authors.lastname: Casbard
authors.forename: Sally
authors.initials: S
authors.lastname: Ballard
authors.forename: Ira A
authors.initials: IA
authors.lastname: Shulman
authors.forename: Nancy
authors.initials: N
authors.lastname: Heddle
authors.forename: James P
authors.initials: JP
authors.lastname: Aubuchon
authors.forename: Silvano
authors.initials: S
authors.lastname: Wendel
authors.forename: Amanda
authors.initials: A
authors.lastname: Thomson
authors.forename: Tor
authors.initials: T
authors.lastname: Hervig
authors.forename: Katharine
authors.initials: K
authors.lastname: Downes
authors.forename: Patricia M
authors.initials: PM
authors.lastname: Carey
authors.forename: Walter H
authors.initials: WH
authors.lastname: Dzik
mesh_terms: D001788:Blood Grouping and Crossmatching / Q000379:methods*; D001803:Blood Transfusion / Q000379:methods*; D005500:Follow-Up Studies; D006753:Hospital Records; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D010355:Patient Identification Systems / Q000379:methods*; D012107:Research Design; D013997:Time Factors