title: Blood transfusions in critical care: improving safety through technology & process analysis.
abstract: A multidisciplinary safety initiative transformed blood transfusion practices at St. Luke's Episcopal Hospital in Houston, Texas. An intense analysis of a mistransfusion using the principles of a Just Culture and the process of Cause Mapping identified system and human performance factors that led to the transfusion error. Multiple initiatives were implemented including technology, education and human behaviour change. The wireless technology of Pyxis Transfusion Verification by CareFusion is effective with the rapid infusion module efficient for use in critical care. Improvements in blood transfusion safety were accomplished by thoroughly evaluating the process of transfusions and by implementing wireless electronic transfusion verification technology. During the 27 months following implementation of the CareFusion Transfusion Verification there have been zero cases of transfusing mismatched blood.
authors.affiliation: Cardiovascular and Transplant Nursing, St Luke's Episcopal Hospital, 6720 Bertner Avenue, MC: 4-278, Box 76, Houston, TX 77030, USA. raulbach@sleh.com
authors.forename: Rebecca K
authors.initials: RK
authors.lastname: Aulbach
authors.forename: Kathy
authors.initials: K
authors.lastname: Brient
authors.forename: Marie
authors.initials: M
authors.lastname: Clark
authors.forename: Kristi
authors.initials: K
authors.lastname: Custard
authors.forename: Carolyn
authors.initials: C
authors.lastname: Davis
authors.forename: Jonathan
authors.initials: J
authors.lastname: Gecomo
authors.forename: Judy Ong
authors.initials: JO
authors.lastname: Ho
mesh_terms: D000368:Aged; D001803:Blood Transfusion / Q000451:nursing; D034201:Computers, Handheld; D003422:Critical Care / Q000458:organization & administration*; D005260:Female; D006457:Hemoglobinuria, Paroxysmal; D016519:Hospitals, Religious; D006784:Hospitals, Teaching; D006801:Humans; D019300:Medical Errors / Q000009:adverse effects / Q000451:nursing / Q000517:prevention & control*; D010043:Outcome and Process Assessment, Health Care / Q000458:organization & administration*; D010348:Patient Care Team; D010355:Patient Identification Systems / Q000458:organization & administration*; D017751:Safety Management / Q000458:organization & administration*; D013597:Systems Analysis; D013781:Texas; D017749:Total Quality Management / Q000458:organization & administration; D065227:Transfusion Reaction