Recommendations for the electronic pre-transfusion check at the bedside.

Abstract

The current risk of acquiring viral transmission through blood components is very small1. Thus, serious non-infectious hazards of transfusion have emerged as the most common complications2. The risk of non-infectious complications, including risks related to hospital-based steps in transfusion care, is at least 100 times greater than the risk of acquiring human immunodeficiency virus or hepatitis C virus infection through blood components3. One of the most frequent causes of transfusion-associated morbidity or mortality is mistransfusion, when the wrong blood is transfused to the wrong patient. Mistransfusion is the final outcome of one or more procedural errors or technical failures in the transfusion process, starting with the decision to transfuse a patient and ending with the actual administration of blood components3. In particular, ABO-incompatible transfusions attributable to incorrect identification of the patient or the blood unit are among the most serious transfusion hazards3–5. The Japan Society of Transfusion Medicine and Cell Therapy (JSTMCT) conducted nationwide surveys in Japan regarding ABO-incompatible blood transfusions (1st survey: January 1995–December 1999; 2nd survey: January 2000–December 2004). They found that the main cause of ABO-incompatible transfusion was identification error between the patient and blood unit6. These two surveys reported 9 and 8 “preventable” fatalities, respectively. Mislabelled and wrongly collected patient samples (wrong blood in tube [WBIT]) can also initiate a chain of events leading to mistransfusion3. Thus, correct patient identification at the time of sample collection and administration of blood components is critical. The Serious Hazards of Transfusion (SHOT) scheme in England showed that approximately 70% of incorrect blood component transfused (IBCT) errors take place in clinical areas, with the most frequent error being failure of the final patient identification checking procedure at the bedside; the frequency of IBCT events was calculated as 7 per 100,000 components7. However, the true incidence of mistransfusion seems to be even higher due to a failure to recognise many of the errors, and because complete data on transfusion episodes are not available. Thus, the pre-transfusion checking procedure at the bedside is the most critical step to prevent mistransfusion, and represents the final opportunity to prevent blood component misuse. However, a large observational audit revealed a failure to perform the final bedside checking procedure8, in which the practice compliance of healthcare workers for identification and vital sign monitoring of patients receiving blood transfusions were substandard in many hospitals. Machine-readable identification technology, especially a bar code-based electronic identification system (EIS), is ideally suited for pre-transfusion checking procedures and has been reported to significantly improve transfusion practice9–15. The British Committee for Standards in Haematology (BCSH) Guidelines for the Use of Information Technology (IT) in blood transfusion laboratories were recently up-dated16, providing mainly guidance on the operational use of laboratory information management systems (LIMS). Thus, to our knowledge, there are no available recommendations addressing the issues regarding the pre-transfusion check procedures at the bedside employing an EIS. The JSTMCT Task Force proposed the original draft of recommendations for the electronic pre-transfusion check procedures at the bedside and raised public awareness regarding the draft of recommendations on the home page of the JSTMCT17. The draft of the current recommendations developed by the Task Force adopted the opinions were submitted without major changes to the description. The objective of this study was to establish recommendations for the electronic pre-transfusion checking procedures at the bedside, appropriate for clinical situations, where a bar code-based EIS is used.