1. Paul Ashford

2. Safe Blood? Ensuring the provision of safe blood is a high priority Donor selection Testing Processing Quality assurance But...

3. Safe Blood? Ensuring the provision of safe blood is a high priority Donor selection Testing Processing Quality assurance But... Safe blood given to the wrong recipient can cause death or serious injury

4. Is there a problem? You won’t find a problem if you don’t look for it Haemovigilance systems consistently show that the most frequent errors are ‘Incorrect blood component transfused’

5. UK SHOT Report 2011

6. Identification is the key At each step of the transfusion process, and every other intervention in medicine, identification of the right patient is an absolute essential. SHOT Report 2011

7. Bedside Information Cycle

8. Sample from wrong patient

9. Bedside Information Cycle Sample from wrong patient Results reported against wrong patient identifier

10. Bedside Information Cycle Sample from wrong patient Results reported against wrong patient identifier Patient incorrectly identified

11. Bedside Information Cycle Sample from wrong patient Patient incorrectly identified Request carries wrong patient identifier Results reported against wrong patient identifier

12. Bedside Information Cycle Sample from wrong patient Patient incorrectly identified Request carries wrong patient identifier Sample from wrong patient Results reported against wrong patient identifier

13. Bedside Information Cycle Sample from wrong patient Patient incorrectly identified Request carries wrong patient identifier Samples incorrectly identified Sample from wrong patient Results reported against wrong patient identifier

14. Bedside Information Cycle Sample from wrong patient Patient incorrectly identified Request carries wrong patient identifier Samples incorrectly identified Patient incorrectly matched to products Sample from wrong patient Results reported against wrong patient identifier

15. Types of Error Transcription errors 569237 becomes 569327 Inconsistent or missing identifiers Hospital number; family name; forename; DoB Confusion of identifiers Penny Alison or Alison Penny? (The strange case of Penny Allison) Wrong source of information Inadequate checking

16. Manual Interventions Consistent policies and procedures Adequate training and refreshers Patient wristbands Sufficient identifiers (with redundancy) Double checking Appropriate working conditions Policies for handling errors

17. It should not be used to correct bad practice

18. Automation Interventions Bar coding of blood products Electronically readable patient wristbands Control software

19. Bar coding of blood products Both machine readable and clear text Standard design Use of ISBT 128 international standard Linked automated data capture and effective blood management systems

20. Patient Wristbands Electronic identification of the patient Electronic and human readable Reduces likelihood of identification error ISBT 128 data structures

21. Patient Wristbands Reduces likelihood of identification error – provided it is attached to the correct patient!!!

22. Wristband controls Wristband only to be assigned by specified well trained staff Thorough patient identification procedure prior to printing and affixing wristband Written procedures regarding removal and re-issue of wristbands Patient education regarding importance of wristband

23. Scanners and control systems Bedside scanning systems to capture electronic information Control software linking all phases of the information cycle

24. Norwegian ISBT 128 System Based on ISBT 128 Technical Bulletin 8 Patient has bar coded wristband Blood unit is ISBT 128 labelled Patient wristband scanned at sample collection – tube label generated Blood bank selects compatible blood and generates two part ‘match with unit label’, confirming correct unit At bedside ‘match with unit’ label scanned and patient wristband

25. Patient and Blood bar coded

29. Match with Unit

30. Oxford Hospital System Similar approach to Norwegian system Has additional security of controlled refrigerator access Suitable for ‘remote issue’ situations Staves et al. Transfusion 2008;48:415-424

31. End-to-end electronic transfusion Bar-coded patient ID on the wristband is used to label the sample and blood bag Davies et al. Transfusion 2006; 46: 352-364 slide courtesy of Prof Mike Murphy

32. Bedside Information Cycle

33. Control Systems Scanned patient ID Patient ID automatically associated with request at bedside Samples automatically labelled with bar codes at point of collection Scanned patient ID Confirmed match with blood and reports Scanned patient ID Correct patient confirmed Patient ID transferred automatically to crossmatch report and blood unit label

34. Control Systems Scanned patient ID Patient ID automatically associated with request at bedside Samples automatically labelled with bar codes at point of collection Scanned patient ID Confirmed match with blood and reports Scanned patient ID Correct patient confirmed Patient ID transferred automatically to crossmatch report and blood unit label ???