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Consider a combination system for preventing blood transfusion errors

Nurse Leader Weekly, December 3, 2004

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About 20 patients in the United States will die in 2005 from receiving a blood transfusion meant for someone else. This preventable human error often happens when staff mislabel blood tubes or fail to verify that a patient's identification matches the label on a blood bag.

It's not exactly the DaVinci Code, but the combination system used by Dartmouth-Hitchcock Medical Center has helped the Lebanon, NH-based hospital protect against blood transfusion errors for more than 12 years.

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

The hospital considered implementing a bar-code system to reduce its chance of error, but decided against it at the urging of one of its anesthesiologists. The physician warned that staff who are pressed for time might try to work around a finicky bar-code scanner by visually verifying the bar code rather than scanning it through, says James AuBuchon, MD, chair of pathology at Dartmouth-Hitchcock.

The hospital instead opted to employ the Bloodloc(tm) 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 who receives the blood wears an identification bracelet that bears the three-letter code. Staff can unlock the bag only by using the code.

Result: In 12 years, the system has detected more than 50 incorrectly labeled blood sample tubes and prevented three mistransfusions.

Staff have responded positively to the system. In fact, nurses in the intensive care nursery asked to use the system on their unit. Theirs had been the only unit that didn't receive locks because it transfuses only type O blood.

Risk of error looms: Of course, there's always the chance that a phlebotomist will accidentally write the wrong combination on a blood bag. Dartmouth-Hitchcock may eventually combine the lock system with bar-coding to ensure that this doesn't happen, says AuBuchon.

Source: Adapted from Briefings on Patient Safety (December 2004), published by HCPro, Inc.

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