Patients' positive identification systems.
BACKGROUND
Blood safety must be maintained throughout the whole transfusion chain to prevent the transfusion of incorrect blood components. The estimated risk of an incorrect transfusion is in the order of 1 per 10,000 units of blood. Although several kinds of errors contribute to "wrong blood" events, 70% of errors occur in clinical areas with the most common being due to failure of the pre-transfusion bedside checking procedure.


METHODS
Several methods are available to reduce such errors. The I-TRAC Plus system by Immucor consists of an identification bracelet which is a bar-coded wristband and a handheld portable computer that identifies patients and blood bags by a scanner and prints the information through a portable printer. The labels attached on the blood order forms and on the sample tubes are read and recorded in the blood bank's informatics system (EmoNet INSIEL). Labels showing the bar-code of the assigned number, which includes the ID number of the patient, the ID number of the unit and a code identifying the kind of product and use (allogeneic or autologous), are generated and applied to the blood components. The transfusions are administered after checking the unit and the patient's wristband using the scanner of a portable PC.


RESULTS
In 5 years a total of 71,400 units of blood components were transfused to 15,430 patients using the I-TRAC Plus system. The system prevented 12 cases of mis-identification of patients (5 in 2003, 0 in 2004, 1 in 2005, 1 in 2006 and 5 in 2007).


CONCLUSIONS
In 2003 we introduced the use of a bar-code matching system between a patient's wristband and the blood bag to avoid mistakes at the bedside. In 5 years the system provided benefits by avoiding errors in the identification of patients, thus preventing "wrong blood" transfusions.
Pagliaro
Pasqualepaolo
P
U.O. Immunoematologia e Trasfusionale, Policlinico S.Orsola-Malpighi, Bologna, Italy. pasqualepaolo.pagliaro@aosp.bo.it
Turdo
Rosalia
R
Capuzzo
Enrico
E
D000017:ABO Blood-Group System; D001787:Blood Group Incompatibility / Q000517:prevention & control*; D001803:Blood Transfusion; D001330:Electronic Data Processing / Q000295:instrumentation* / Q000379:methods; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000295:instrumentation*; D012189:Retrospective Studies
D000017:ABO Blood-Group System