title: Variable pre-transfusion patient identification practices exist in the perioperative setting.
abstract: OBJECTIVE
  The operating room (OR) has been identified by hemovigilance systems as a hospital area at high risk for transfusion errors. Where it was confirmed that transfusion products were being administered to the intended patient, we sought to determine the frequency that surgical patients' identification (ID) bands were inaccessible, the procedures used to identify patients when ID bands were inaccessible, and the effect on pre-transfusion bedside checks when ID bands were inaccessible.
  
  
  METHODS
  We tracked the accuracy, location, and accessibility of patient ID bands in the operative phase over three months at a single Canadian Academic Health Sciences Centre. We also evaluated the surgical team's compliance with transfusion policy, focusing on bedside checks.
  
  
  RESULTS
  Forty-four percent of the 426 patients who were tracked had accessible ID bands intraoperatively. The ID bands were removed from 6.3% of surgical patients, primarily for the placement of additional vascular lines. Cardiovascular procedures, which have a high frequency of transfusions, had the highest rate of ID band removals (26.9%) and the third-to-lowest ID band accessibility rate (19.2%). General surgery procedures had the lowest percentage of accessible ID bands (14.8%). Sixty-four of the 77 patients observed receiving transfusions in the OR had inaccessible ID bands due to positioning of the patient's arm, interference from equipment, or the surgeon. No patient ID bands were used at bedside checks, and addressograph cards and anesthetic records were used in place of the ID band in 97.4% and 2.6% of transfusions, respectively.
  
  
  CONCLUSIONS
  Due to intraoperative inacessibility, the system of patient ID banding has inherent limitations as a means for providing consistent pre-transfusion checks in surgical patients. A consistently accessible ID source that is continuously affixed to surgical patients should be introduced in the OR.
authors.affiliation: Department of Transfusion Medicine & Tissue Banks, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
authors.forename: James M
authors.initials: JM
authors.lastname: Burrows
authors.forename: Jeannie L
authors.initials: JL
authors.lastname: Callum
authors.forename: Susan
authors.initials: S
authors.lastname: Belo
authors.forename: Edward
authors.initials: E
authors.lastname: Etchells
authors.forename: Alexandra
authors.initials: A
authors.lastname: Leeksma
mesh_terms: D001803:Blood Transfusion / Q000379:methods*; D006801:Humans; D007430:Intraoperative Care / Q000379:methods / Q000592:standards; D019300:Medical Errors / Q000517:prevention & control*; D009864:Ontario; D010355:Patient Identification Systems / Q000379:methods*; D011446:Prospective Studies; D013503:Surgery Department, Hospital / Q000458:organization & administration / Q000592:standards; D013514:Surgical Procedures, Operative / Q000379:methods / Q000592:standards