Study Examines Bedside Error Rate in Transfusion Medicine

In its landmark report, To Err Is Human (2000), The Institute of Medicine (IOM) estimated that between 44,000 and 98,000 patients die each year as a result of medical errors. These types of reports compel the healthcare community to action. The following describes a study that was undertaken in an effort to reduce bedside errors in transfusion medicine.

An international study found virtually no difference when a tag was placed on blood bags reminding healthcare personnel to check the patient’s wristband to confirm identification before transfusing blood products, according to a study published in the May 2007 issue of Transfusion. Called the Prevention of Bedside Errors in Transfusion Medicine (PROBE-TM) study, the cluster-randomized, matched-paired clinical areas trial was designed to assess the impact of a simple intervention to reduce errors in the pre-transfusion bedside check. Giving patients the wrong blood component is a nagging error associated with transfusion and often involves misidentification of the patient and/or the unit of blood.

The objective of the study was to assess the effect of a simple intervention designed to improve performance of the bedside check and to observe the durability of any effect. The intervention amounted to a tag placed on blood bags reminding staff to check the patient’s wristband. The tag was positioned in such a way that it must be removed to spike the unit.

Led by Michael F. Murphy, MD, a hematologist at The John Radcliffe Hospital and the United Kingdom’s National Blood Service, the research team tested the tag intervention in a multi-center trial incorporating short-term and long-term follow-up periods. The primary endpoint was the proportion of patients transfused with red cell units for whom the key elements of the bedside check were all correctly completed.

Fifteen matched-paired clinical areas at 12 hospitals in six countries participated in the trial. Combining data from all the hospitals, the bedside check was correctly performed in 37 percent of transfusions during the baseline audit period.

The study found no evidence of a favorable effect of the intervention immediately after its introduction. Similarly, there was no evidence of a favorable effect after continued use of the intervention for an additional eight weeks. Thus, the tag failed to improve bedside transfusion practice, though the authors say “the robust design developed for this study could be applied to investigate other interventions to improve the safety of bedside transfusion practice.”

In a related editorial, Harold Kaplan, MD, of Columbia Presbyterian Medical Center in New York, said the researchers’ “appealingly simple approach” and “elegantly designed study did not demonstrate efficacy of the intervention … even though the sticker acted as a behavior shaping device and forced a stop. Perhaps the action ultimately forced was to stop to remove the sticker rather than to check the patient’s wristband. Ideally a forcing function would eliminate the possibility of proceeding if the required step was not first carried out.”

In conclusion, the results of the 2000 IOM study prompted the healthcare community to further scrutinize ourselves and to improve patient safety. In addition, accrediting agencies such as the College of American Pathologists (CAP) began adding more patient safety questions to their inspection protocols such as “Does the laboratory have a plan to implement a system to reduce the risk of mistransfusion for non-emergent red cell transfusions?” (TRM.30575) – a question listed on the most current version of the CAP Transfusion Medicine Checklist.

Bonfils’ Immunohematology Reference Laboratory has a widely utilized protocol in place to help transfusing facilities avoid mistransfusion. All samples requiring crossmatches that are delivered to our laboratory must be properly labeled with items that are listed in the 24^th Edition of AABB Standards for Blood Banks and Transfusion Services (patient first and last name, draw date, identification number, etc). In addition, each sample must be accompanied by a requisition that contains sufficient information for positive identification of the recipient, and this information must match what is on the sample. This patient identification information is entered into our computer system. Once compatibility testing is complete, a crossmatch tag containing the same patient identification information will print directly from our computer system. This tag is attached to the blood component that is to be transfused.  Once the component arrives at the transfusing facility, a bedside check (preferably performed by two professionals) must be performed to assure that the information on the printed tag, the component label and the patient’s wristband all match. And finally, the bedside check must take place before the infusion of the product begins.

Citations: Murphy, MF et al. Prevention of bedside errors in transfusion medicine (PROBE-TM) study: a cluster-randomized, matched-paired clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check. Transfusion 2007;47:771-780. Kaplan, H. Safer design.Transfusion2007;47;758-59 􀀶

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