title: Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors.
abstract: OBJECTIVE
  To determine whether the use of a computerized bar code-based blood identification system resulted in a reduction in transfusion errors or near-miss transfusion episodes.
  
  
  METHODS
  Our institution instituted a computerized bar code-based blood identification system in October 2006. After institutional review board approval, we performed a retrospective study of transfusion errors from January 1, 2002, through December 31, 2005, and from January 1, 2007, through December 31, 2010.
  
  
  RESULTS
  A total of 388,837 U were transfused during the 2002-2005 period. There were 6 misidentification episodes of a blood product being transfused to the wrong patient during that period (incidence of 1 in 64,806 U or 1.5 per 100,000 transfusions; 95% CI, 0.6-3.3 per 100,000 transfusions). There was 1 reported near-miss transfusion episode (incidence of 0.3 per 100,000 transfusions; 95% CI, <0.1-1.4 per 100,000 transfusions). A total of 304,136 U were transfused during the 2007-2010 period. There was 1 misidentification episode of a blood product transfused to the wrong patient during that period when the blood bag and patient's armband were scanned after starting to transfuse the unit (incidence of 1 in 304,136 U or 0.3 per 100,000 transfusions; 95% CI, <0.1-1.8 per 100,000 transfusions; P=.14). There were 34 reported near-miss transfusion errors (incidence of 11.2 per 100,000 transfusions; 95% CI, 7.7-15.6 per 100,000 transfusions; P<.001).
  
  
  CONCLUSIONS
  Institution of a computerized bar code-based blood identification system was associated with a large increase in discovered near-miss events.
authors.affiliation: Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA. gnuttall@mayo.edu
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Nuttall
authors.forename: John P
authors.initials: JP
authors.lastname: Abenstein
authors.forename: James R
authors.initials: JR
authors.lastname: Stubbs
authors.forename: Paula
authors.initials: P
authors.lastname: Santrach
authors.forename: Mark H
authors.initials: MH
authors.lastname: Ereth
authors.forename: Pamela M
authors.initials: PM
authors.lastname: Johnson
authors.forename: Emily
authors.initials: E
authors.lastname: Douglas
authors.forename: William C
authors.initials: WC
authors.lastname: Oliver
mesh_terms: D058731:Blood Safety / Q000379:methods*; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D001330:Electronic Data Processing; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D010355:Patient Identification Systems; D011356:Product Labeling; D015397:Program Evaluation; D012189:Retrospective Studies