Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative Blood Component Administration

Nadia B. Hensley, Colleen G. Koch, Peter J. Pronovost, Bommy Hong Mershon, Joan Boyd, Susan Franklin, Dana Moore, Kristen Sheridan, Anne Steele, Tracey L. Stierer

Research output: Contribution to journalArticle

Abstract

Background: Confirmation of match between patient and blood product remains a manual process in most operating rooms (ORs), and documentation of dual-signature verification remains paper based in most medical institutions. A sentinel event at Johns Hopkins Hospital in which a seriously ill patient undergoing an emergent surgical procedure was transfused with a unit of incompatible red blood cells that had been intended for another patient in an adjacent OR led the hospital to conduct a quality improvement project to improve the safety of intraoperative blood component transfusions. Methods: A multidisciplinary quality improvement project team led a four-phase implementation of bedside bar code transfusion verification (BBTV) for intraoperative blood product administration. Manual random sample audits of blood component transfusions were used to examine accuracy of documentation from July 2014 through June 2016. After the transition to the Epic anesthesia information management system (AIMS) in July 2016, automated Epic reports were generated to provide population-level audits. Results: After initiation of BBTV and the addition of Epic AIMS, compliance with obtaining three metrics on documentation of patient identification (two electronic signatures, start and stop times of transfusion, and blood volume transfused) was improved during a one-year period to > 96%. Pre-Epic audits had shown a mean compliance of only 86%, mainly reflecting a lack of paper blood component requisitions. Conclusion: By implementing BBTV and using a novel intraoperative documentation process within the Epic AIMS, a safer process of blood transfusion in the ORs was initiated and documentation improved.

Original languageEnglish (US)
JournalJoint Commission Journal on Quality and Patient Safety
DOIs
StateAccepted/In press - Jan 1 2018

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Blood Transfusion
Documentation
Management Information Systems
Technology
Operating Rooms
Blood Component Transfusion
Automatic Data Processing
Anesthesia
Quality Improvement
Blood Volume
Erythrocytes
Safety
Population

ASJC Scopus subject areas

  • Leadership and Management

Cite this

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title = "Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative Blood Component Administration",
abstract = "Background: Confirmation of match between patient and blood product remains a manual process in most operating rooms (ORs), and documentation of dual-signature verification remains paper based in most medical institutions. A sentinel event at Johns Hopkins Hospital in which a seriously ill patient undergoing an emergent surgical procedure was transfused with a unit of incompatible red blood cells that had been intended for another patient in an adjacent OR led the hospital to conduct a quality improvement project to improve the safety of intraoperative blood component transfusions. Methods: A multidisciplinary quality improvement project team led a four-phase implementation of bedside bar code transfusion verification (BBTV) for intraoperative blood product administration. Manual random sample audits of blood component transfusions were used to examine accuracy of documentation from July 2014 through June 2016. After the transition to the Epic anesthesia information management system (AIMS) in July 2016, automated Epic reports were generated to provide population-level audits. Results: After initiation of BBTV and the addition of Epic AIMS, compliance with obtaining three metrics on documentation of patient identification (two electronic signatures, start and stop times of transfusion, and blood volume transfused) was improved during a one-year period to > 96{\%}. Pre-Epic audits had shown a mean compliance of only 86{\%}, mainly reflecting a lack of paper blood component requisitions. Conclusion: By implementing BBTV and using a novel intraoperative documentation process within the Epic AIMS, a safer process of blood transfusion in the ORs was initiated and documentation improved.",
author = "Hensley, {Nadia B.} and Koch, {Colleen G.} and Pronovost, {Peter J.} and Mershon, {Bommy Hong} and Joan Boyd and Susan Franklin and Dana Moore and Kristen Sheridan and Anne Steele and Stierer, {Tracey L.}",
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T2 - Leveraging Technology to Overcome Human Error in Intraoperative Blood Component Administration

AU - Hensley, Nadia B.

AU - Koch, Colleen G.

AU - Pronovost, Peter J.

AU - Mershon, Bommy Hong

AU - Boyd, Joan

AU - Franklin, Susan

AU - Moore, Dana

AU - Sheridan, Kristen

AU - Steele, Anne

AU - Stierer, Tracey L.

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