Improving the safety of the blood transfusion process
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Contributor(s):
- Pennsylvania. Patient Safety Authority. Institute for Safe Medication Practices. ECRI (Organization)
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2010
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Blood Component Transfusion -- methods Blood Transfusion -- methods Medical Errors -- prevention & control Quality Control Safety Management Automatic Data Processing Blood Banks Blood Component Transfusion -- adverse effects Blood Group Incompatibility Patient Identification Systems Practice Guidelines as Topic Risk Management Transfusion Reaction Humans United States
- Genre(s):
- Technical Report
- Abstract:
- Patient death or disability associated with incompatible blood is one of the Centers for Medicare and Medicaid Services Hospital-Acquired Conditions and is listed as one of the National Quality Forum's Serious Reportable Events. The Joint Commission's 2009 National Patient Safety Goal 01.03.01 lists the elimination of transfusion errors related to patient identification. Blood component transfusions to nondesignated recipients occur in about 1 of 10,000 transfused units. Two-thirds of these errors are associated with incorrect blood recipient identification occurring at the patient's bedside. There were 535 reports of blood transfusion-related events submitted to the Pennsylvania Patient Safety Authority during the 13-month period from July 2008 through July 2009. Reports involved mismatched units; events related to blood component collection; blood products dispensed, distributed, or administered; or wrong patients being transfused. Recipient identification at blood collection and administration are essential to the safety of the total blood transfusion process. The safe transfusion of blood components is a complex process involving many departments, multiple staff, and several steps. This article focuses on the process for safe transfusion and the risk reduction strategies that decrease the incidence of transfusion errors by developing adequate quality systems to ensure correct patient identification of the transfusion candidate, assigning clear responsibilities to qualified staff including a transfusion safety officer, and using identification technologies such as bar-coding or radiofrequency identification tags.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101546441 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101546441