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Tip of the Week: Three tips to reduce blood transfusion errors

Accreditation Connection, May 9, 2005

Twenty patients in the United States died in 2004 when staff mislabeled blood tubes or failed to verify a patient's identification. Here are three tips to avoid blood transfusion errors.

1. Use two blood samples

University Hospital in Cleveland requires two blood samples for new patients to avoid deadly blood transfusion errors. The Ohio hospital implemented the policy in 2003.

The second sample helps ensure that the patient's first sample was properly labeled and identified. Staff drew it at a separate time and in a differently labeled tube. Then they match it against the patient's identification and first blood sample.

"The requisition tube is a shocking pink with a bright pink label," says Mary Ann Inck, quality assurance manager in the hospital's blood bank. The pink tube is only available for the second draw. This prevents staff from working around the policy by drawing the second sample at the same time as the first.

2. Use bar coding to ensure accuracy

Nurses at Georgetown University Hospital prefer to double-check identification electronically rather than summon another busy nurse to verify the information visually, says Gerald Sandler, MD, director of transfusion medicine at the Washington, DC-based facility.

Before instituting a bar-code labeling system, nursing unit request forms or tube labels were unclear 15% of the time. This meant that blood bank personnel had to call the nursing unit to learn whether "Jim Smith" and "James Smith" was the same person.

The blood bank requires all information on requests to match a patient's identification exactly. Georgetown meets this degree of precision by using a bar-code system that prints labels clearly and accurately.

3. Alternative to bar codes: Use a combination system

When Dartmouth-Hitchcock Medical Center in Lebanon, NH changed locations in 1991, the blood bank was no longer located near patient units. This increased Dartmouth-Hitchcock's risk of transfusion errors because blood bank staff no longer performed phlebotomies and blood orders were now taken by phone at the blood bank.

The hospital thought about implementing a bar-code labeling system but a physician warned that staff pressed for time might try to work around a finicky bar-code scanner by visually verifying the bar code rather than scanning it through.

The hospital instead opted to employ the BloodlocT safety system, which involves placing each bag of blood inside a "locked" plastic bag. The bag locks cost about $3-$4 each and feature three rings that fit together. Each ring has 26 letters, providing 12,000 possible combinations. The patient receiving the blood wears an identification bracelet that bears the three-letter code. Staff can unlock the bag only by using the code.

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