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Large-scale and long-term studies are not sufficient to determine the efficiency that IT solutions can bring to transfusion safety.
This quality-improvement report describes our continuous efforts to implement and upgrade a bar code–based transfusion management (BCTM) system since 2011 and examines its effectiveness and sustainability in reducing blood transfusion errors, in a 3000-bed tertiary hospital, where more than 60,000 prescriptions of blood transfusion are covered by 2500 nurses each year.
The BCTM system uses barcodes for patient identification, onsite labeling, and blood product verification, through wireless connection to the hospital information systems. Plan-Do-Study-Act (PDSA) cycles were used to improve the process. Process maps before and after implementation of the BCTM system in 2011 were drawn to highlight the changes. The numbers of incorrect labeling or wrong blood in tube incidents that occurred quarterly were plotted on a run chart to monitor the quality changes of each intervention introduced. The annual occurrences of error events from 2011 to 2017 were compared with the mean occurrence of 2008-2010 to determine whether implementation of the BCTM system could effectively reduce the number of errors in 2016 and whether this reduction could persist in 2017.
The error rate decreased from 0.03% in 2008-2010 to 0.002% in 2016 (
This report demonstrates that continuous efforts to upgrade the existing process is critical to reduce errors in transfusion therapy, with support from information technology.
Blood transfusion is a complex multistep process that includes confirming the doctors’ prescriptions, sampling and testing the patients’ blood, preparing and storing the blood components, and delivering the needed components to patients. These steps, involving members of several different professional groups, have several hotspots for errors that need to be checked to protect transfusion safety [
Despite many efforts to prevent transfusion errors, there is room for improvement. In the 2017 annual report of Serious Hazards of Transfusion (SHOT), an independent, professionally led hemovigilance scheme of the United Kingdom, clearly states that “...Many such errors could be attributed to system faults and others to what we now call ‘human factors’...we must design our practices and systems to minimise the impact...” SHOT recommends that “All available information technology [IT] systems to support transfusion practice should be considered and these systems implemented to their full functionality...” for the management and the transfusion teams of hospitals [
Although the application of new technology could simplify the complexity of routine procedures and an end-to-end electronic system could help further improve transfusion safety [
The objectives of this paper are to describe our efforts since 2011 to develop a bar code–based transfusion management system (BCTM) and to test if full implementation of BCTM in our hospital, a 3000-bed tertiary care hospital, could result in a significant reduction in transfusion errors in 2016 and whether this reduction could persist in 2017.
This is a retrospective study. The format of this quality improvement report follows the Standards for QUality Improvement Reporting Excellence (SQUIRE 2.0) guidelines [
The study hospital has approximately 2500 first-line nurses to deliver more than 5000 blood transfusion therapies each month. Based on the International Business Machines (IBM) framework built in 1982, the hospital information system (HIS) consists of many subsystems such as the computerized physician order entry (CPOE) system, the laboratory information system (LIS), the pharmacy information system, and the nursing information system (NIS). Although each subsystem has been developed and evolved over time to serve particular needs, these subsystems are all linked within the HIS. The unique patient identification (ID) number is the key to retrieve relevant information for a particular patient from the HIS. With the completion of the whole-hospital wireless system and the deployment of mobile nursing carts, which are equipped with an industrial computer wirelessly linked to the HIS, in 2009, it became possible for nurses to retrieve and verify relevant information at bedside for patient-centered services. The bar code medication administration (BCMA) system, deployed in 2010, was the first system in the study hospital to use barcode scanning of the patient’s wristband for patient ID.
Inspired by Murphy’s [
The project team first reviewed the root causes of the 41 wrong labeling incidents that occurred in 2008-2010 and found that 17 incidents (41%) were caused by staff being interrupted by other urgent issues and 6 mistakes (14%) were related to complicated sticker and paper requisition forms (
These findings suggest the need for a close working environment to avoid interruptions, less complicated sticker/paper forms, and streamlined procedures to improve compliance.
The BCTM project team also reviewed the process of blood sampling (
Under daily routine situations, to avoid repeat blood drawing from a patient, all types of blood samples for each patient are collected together in the early morning. Under emergency conditions, the nurse performs the blood sampling immediately.
The causes of errors of labeling in 2008-2010 (N=41).
Causes of errors | Value, n (%) |
Interrupted by other urgent issues | 17 (41) |
Staff unfamiliar with the procedure | 9 (22) |
Staff deviated from the standard operating procedure | 5 (12) |
Understaffing to perform double check at bedside | 4 (10) |
Patient’s sticker misplaced | 3 (7) |
Wrong stickers or requisition on sample tube/bag | 3 (7) |
Process changes in blood sampling for grouping.
Before BCTMa | After BCTM |
HISb terminal prints out order for blood typing at the station Ward clerk notifies nurse providing care Nurse confirms the order from medical chart and puts the standing orders into a box for blood sampling the next morning |
HIS terminal prints out order for blood typing at the station Ward clerk notifies nurse providing care Nurse confirms the order from a mobile unit |
Early morning shift nurse brings the prelabeled tubes and paper requisition forms to bedside Talks to the patient of the upcoming procedures Performs two-person verification of patient identification and order by reading out and repeating the necessary information on the patient’s ID and requisition forms Draws blood for typing and fills into the prelabeled tube Two nurses double sign the requisition form Wraps the filled prelabeled tube with the requisition form Returns wrapped tubes to station The ward clerk writes down the requisition number of all tubes on a list for sample tracking The porter signs the list and sends the samples to the blood bank |
Early morning shift nurse moves to bedside with a phlebotomy cart Talks to the patient of the upcoming procedures Scans patient’s wristband for patient ID and verifies orders through the BCTM system Draws blood for typing and fills into the selected tube After the second staff verifies data through BCTM, a sticker containing necessary information and barcodes is printed out for on-site labeling Wraps the labeled tube with paper requisition form (discontinued after June 2013) Returns the labeled tube to the station The porter scans each sample’s barcode and sends the samples to the blood bank |
aBCTM: Bar Code based Transfusion Management.
bHIS: hospital information system.
cID: identification.
Based on the abovementioned review, the BCTM team adopted the scanning of wristband barcodes of patient ID for timely verification and documentation on each transaction of transfusion therapy from all relevant subsystems (ie, CPOE, LIS, and NIS) of HIS and proposed the following three major changes: (1) label sample tubes at bedside, (2) redesign the end-to-end tracking of transfusion therapy, and (3) provide step-by-step reminders. The standard procedures for blood sampling and blood product administration were also updated accordingly (
Process changes in blood product administration.
Before BCTMa | After BCTM |
Blood product arrives at the nursing station Ward clerk notifies the caring nurse Nurse checks the information of the blood product and the standing prescription of transfusion from medical chart of the patient |
Blood product arrives at the Nursing Station Ward clerk notifies the caring nurse Nurse scans the barcode on the blood bag to verify the transfusion prescription and the right blood product in BCTM |
Nurse brings the blood product and medical chart/paper order to the bedside Talks to the patient of the upcoming procedures Performs two-person verification by reading out and repeating the information of patient identification, blood bag content, and the prescription of transfusion therapy Starts transfusion and monitoring Records patient’s responses to transfusion into the NISc Writes on the paper form of transfusion reaction record of patient’s response Returns transfusion record to the station to confirm the completion of the transfusion Ward clerk sends the paper record to the blood bank for tracking |
Nurse brings the blood product to the patient with a nursing cart Talks to the patient of the coming procedures Scans patient’s wristband IDb and the barcode on the blood bag to verify the order in BCTM A second staff member repeats the abovementioned processes Starts transfusion and monitoring Records patient’s responses to transfusion into the NIS Generates transfusion reaction record from NIS Confirms the completion of transfusion through BCTM for electronic tracking |
aBCTM: Bar Code based Transfusion Management.
bID: identification.
cNIS: nursing information system.
A label printer and three drawers for different types of blood sampling tubes are added to the mobile nursing cart (
Layout of the phlebotomy cart. BCTM: bar code–based transfusion management; ID: identification; HIS: hospital information system; NIS: Nursing Information System.
Barcodes used for the BCTM system. BCTM: bar code–based transfusion management; ID: identification.
As our Blood Centre laboratory and Transfusion Medicine Department has been accredited by the College of American Pathologists since 2003, we did not change the practices and processes in the Blood Centre, but have instead worked with them to develop appropriate barcode systems and link necessary information from the Blood Bank computer system with the HIS/NIS/BCTM to accomplish the electronic tracking of blood products. After the compatibility test for a prescription of transfusion therapy, a specific barcode assigned by the BCTM for the compatible blood product bag is labeled for tracking, while the original process to label the readable information of the blood bag remains unchanged (
Training for staff on standard procedures has been a challenge in our hospital, as we have approximately 2500 nurses to cover more than 5000 transfusion monthly. Staff that are unfamiliar with the procedure (22%) or deviate from standard procedures (12%) were major reasons of errors in 2008-2010 (
In the study hospital, the Transfusion Safety Committee (TSC), which consists of representatives from the Nursing Department, Blood Centre, Clinical Laboratory, and Transfusion Medicine Department, governs transfusion safety and quality. The TSC meets quarterly to review errors (or near-miss incidents including incorrect labeling detected upon receipt by the Blood Centre, WBIT identified from the patient’s historical record in the HIS, or WBIT after resampling and rechecking by the Blood Centre if the first grouping result is not consistent with the patient’s own statement of blood type) and incorrect transfusion case reports presented by the Blood Centre and directs quality improvement actions. After a 3-month pilot run of the proposed BCTM system in two 40-bed wards to test its feasibility and to collect feedback from nurses to fine tune the process, the TSC approved a stepwise deployment of the BCTM system with the updated procedures and the use of phlebotomy carts, starting from regular wards and intensive care units in January 2011. The TSC granted the implementation of the BCTM into operation rooms in 2015 and emergency services in 2016.
The project team reports the progress and quality indicator changes of the implementation of the BCTM system to the TSC. The number of occurrences of near-miss incidents during each quarter is plotted on a run chart by the BCTM project team to describe the progress of quality changes after interventions. An objective of reducing the number of near-miss events to fewer than three incidents per quarter was set as the goal, and the median of four quarterly near-miss incidents (from January 2008 to December 2010) was the baseline before the introduction of the BCTM system (
Run chart of near-miss incidents by quarter. BCTM: bar code–based transfusion management; ID: identification.
The work of the batch preparation of sample tubes using preprinted labels was released from night shift nurses due to on-site labeling (
Incident reports of near-miss cases from January 1, 2008, to December 31, 2017, were retrieved from TSC quarterly meeting records and were reviewed and categorized by the authors of this report. The numbers of prescriptions for blood type matching by year from 2008 to 2017 were retrieved from the HIS for the annual error rate calculation. The number of occurrences of near-miss events by year from 2011 to 2017 was compared to the mean number of annual occurrences of near-miss incidents in 2008-2010, to examine if the introduction of the BCTM system in 2011 could have reduced errors. The number of occurrences of near-miss events by year from 2014 to 2017 was also compared to the mean annual occurrence of near-miss incidents in 2011-2013 to reveal the impact of the discontinuation of wrapping paper requisition forms around the labeled sample tubes after June 2013. Poisson statistics in Microsoft Excel (using the POISSON.DIST function. Version 2010. Redmond, WA: Microsoft Corp), assuming each occurrence was independent and rare (approximately 60,000 orders for blood matching were placed each year), was used to test if the error reduction brought by the BCTM and if the mentioned interventions were statistically significant (
After introduction of the BCTM, the quarterly numbers of near-miss incidents met our objective to have less than three events per quarter, from quarter 1 in 2011 until quarter 3 in 2012 (
With elimination of wrapping paper requisition around labeled tubes in June 2013, a median quarterly number of two near-miss events from January 2011 to June 2013 was set as an updated performance baseline (
The deployment of the BCTM system was performed stepwise, starting from the regular wards and intensive care units in 2011 to the operation rooms in 2015 and finally to the emergency services in 2016. Compared to the mean annual occurrence of 14 near-miss events in 2008-2010, the annual occurrence of near-miss events was significantly reduced after the introduction of BCTM (except in 2013 [
The occurrence of near-miss incidents by year.
Type of error | Year | |||||||||
|
2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 |
Identifier on sample tube and requisition not consistent | 7 | 7 | 3 | 3 | 1 | 4 | 5 | 0 | 1 | 0 |
Identifier on sample tube incomplete or missed | 5 | 6 | 2 | 2 | 3 | 2 | 1 | 3 | 0 | 1 |
Identifier for ABO testing and/or requisition not double verified | 1 | 2 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 |
Inconsistency of the identifiers on the sample tube and ABO testing label | 0 | 4 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 |
WBITa | 2 | 0 | 2 | 1 | 3 | 2 | 1 | 1 | 1 | 0 |
Total cases of wrong labeling and/or WBIT | 15 | 19 | 8 | 7 | 7 | 9 | 7 | 4 | 2 | 1 |
Number of doctor’s orders | 47,756 | 50,645 | 53,346 | 51,313 | 57,337 | 56,389 | 57,406 | 59,771 | 61,563 | 68,326 |
Annual error rates of incorrect labeling and/or WBIT (%) | 0.03 | 0.04 | 0.02 | 0.01 | 0.01 | 0.02 | 0.01 | 0.01 | 0.002 | 0.001 |
Cumulative Poisson probability of near-miss occurrencec | —b | — | — | .03 | .03 | .109 | .03 | .002 | <.001 | <.001 |
Cumulative Poisson probability of near-miss occurrenced | — | — | — | — | — | — | .5 | .12 | .018 | .004 |
aWBIT: wrong blood in tube with correct label.
bNot applicable.
cBased on the average occurrence in 2008-2010, mean=14.
dBased on the average occurrence in 2011-2013, mean=7.67.
With the full implementation of BCTM in 2016, the discontinuation of paper requisitions wrapping in 2013, and the introduction of wristband-specific patient ID barcode in 2015, the reduction in error occurrence in 2016 was statistically significant (
The near-miss events reported here were detected by our Blood Centre when receiving and testing the samples. These reports have not included the near-miss incidents intercepted before leaving the nursing stations; hence, an underestimation of near-miss events may have occurred, especially before implementation of the BCTM system. With the current BCTM system, the need to check the correctness of the label at the nursing stations before sending out the sample to the Blood Centre is reduced, as only one label is used on site, providing fewer opportunities for errors and less possibilities of underreporting.
The implementation of BCTM addresses most of the major challenges identified by the root cause analysis of the 41 near-miss incidents that occurred in 2008-2010 (
The deployment of nursing carts and phlebotomy carts enable us to deliver patient-centered care at bedside. Although it is difficult to provide a cost-effectiveness estimation of our investment to the BCTM, we believe the monetary cost is considerably less than that estimated in the past [
The surge of near-miss incidents in quarter 4 of 2012 and the first half of 2013 (
“Workarounds” in the BCMA, that is, staff members scanning barcodes that contain patient ID information from the working environment but not from the wristband of the patient [
According to the log of the nursing practice in the NIS, the compliance with the barcode scanning of patients’ wristbands reached 97% in 2017 (data on file). There were still circumstances that caused staff members to bypass the electronic system for urgent management. Standard procedures of paper-based blood sampling and transfusion management systems are still effective in our hospital, but are reserved for system failures or other urgent situations.
Although we observed the initial success of our BCTM from quarter 1 in 2011 until quarter 3 in 2012, when the objective to have less than three events per quarter was reached, the initial reduction in errors was not sustained (
Nevertheless, it is interesting to note that in 2017, a filled sample tube with no label on it was received by the Blood Centre and it was later found that the printed sticker was still left in the printer on the phlebotomy cart. This case shows that human errors still occur on occasions. The need for full attention from caring staff cannot be totally replaced by a computer-assisted system. We are still monitoring the trend and conducting quarterly review meetings with our TSC to ensure transfusion safety.
Bar Code Medication Administration
Bar Code based Transfusion Management
Computerized Physician Order Entry
hospital information system
International Business Machines
unique patient identification
information technology
Laboratory Information System
Nursing Information System
Plan-Do-Study-Act
Serious Hazards of Transfusion
Standards for QUality Improvement Reporting Excellence
Transfusion Safety Committee
wrong blood in tube
We thank the nursing staff and Transfusion Safety Committee and Blood Centre of the study hospital for their strong support in this BCTM project.
S-SC led the project and wrote this paper. Y-JC provided insights of transfusion therapy and reviewed the incident data from the Blood Centre, and Y-TS programmed the BCTM subsystem with Java language. H-FY and S-CK coordinated the projects as Nursing Informatics leads and helped analyze the data.
None declared.