New technology for transfusion safety

British Journal of Haematology

Volumn 136, Issue 2, 2007, Pages 181-190

  Dzik, Walter H ^a  

^a MASSACHUSETTS GENERAL HOSPITAL   (United States)

Author keywords

Barcode; Blood transfusion; Errors; Radiofrequency identification; Safety

Indexed keywords

BLOOD ANALYSIS; BLOOD COMPATIBILITY; BLOOD COMPONENT; BLOOD GROUP INCOMPATIBILITY; BLOOD SAMPLING; BLOOD TRANSFUSION; DEMOGRAPHY; HEALTH CARE; HEALTH CARE PRACTICE; HEMATOLOGICAL PROCEDURES; HUMAN; INFORMATION SYSTEM; MECHANICAL PROBE; MEDICAL DECISION MAKING; MEDICAL ERROR; MEDICAL PRACTICE; MEDICAL RECORD; MEDICAL TECHNOLOGY; NANOSENSOR; NANOTECHNOLOGY; PATIENT CARE; PATIENT CODING; PATIENT IDENTIFICATION; PATIENT SAFETY; PRIORITY JOURNAL; PUMP; REVIEW; STANDARDIZATION;

BLOOD GROUPING AND CROSSMATCHING; BLOOD SPECIMEN COLLECTION; BLOOD TRANSFUSION; CLINICAL PHARMACY INFORMATION SYSTEMS; HUMANS; MEDICAL ERRORS; PATIENT IDENTIFICATION SYSTEMS; PATIENT SELECTION; POINT-OF-CARE SYSTEMS; SAFETY MANAGEMENT;

EID: 33845893346     PISSN: 00071048     EISSN: 13652141     Source Type: Journal    
DOI: 10.1111/j.1365-2141.2006.06373.x     Document Type: Review

References (43)

1. Aller, R. (2005) Positive patient identification: more than a double check. CAP Today, 26-34.
2. Andreu, G., Morel, P., Forestier, F., Debeir, J., Rebibo, D., Janvier, G. & Herve, P. (2002) Hemovigilance network in France: organization and analysis of immediate transfusion incident reports from 1994 to 1998. Transfusion, 42, 1356-1364.
3. Anonymous. (2005) Radio-frequency identification: its potential in healthcare. Health Devices, 34, 149-160.
4. Ash, J.S., Berg, M. & Colera, E. (2004) Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. Journal of the American Medical Informatics Association, 11, 104-112.
5. Bates, D.W., Leape, L.L., Cullen, D.J., Laird, N., Petersen, L.A., Teich, J.M., Burdick, E., Hickey, M., Kleefield, S., Shea, B., Vander Vliet, M. & Seger, D.L. (1998) Effect of computerized order entry and a team intervention on prevention of serious medication errors. Journal of the American Medical Association, 280, 1311-1313.
6. Bates, D.W., Teich, J., Lee, J., Seger, D., Kuperman, G.J., Ma'Luf, N., Boyle, D. & Leape, L. (1999) The impact of computerized order entry on medication error prevention. Journal of American Medical Informatics Association, 6, 313-332.
7. Chan, J.C., Chu, R.W., Young, B.W., Chan, F., Chow, C.C., Pang, W.C., Chan, C., Yeung, S.H., Chow, P.K., Lau, J. & Leung, P.M. (2004) Use of an electronic barcode system for patient identification during blood transfusion: 3 year experience in a regional hospital. Hong Kong Medical Journal, 10, 166-171.
8. Chiaroni, J., Legrand, D., Dettori, I. & Ferrara, V. (2004) Analysis of ABO discrepancies occurring in 35 French hospitals. Transfusion, 44, 860-864.
9. Cina, J.L., Gandhi, T.K., Churchill, W., Fanikos, J., McCrea, M., Mitton, P., Rothschild, J.M., Featherstone, E., Keohane, C., Bates, D.W. & Poon, E.G. (2006) How many hospital pharmacy medication dispensing errors go undetected? Joint Commission Journal on Quality and Patient Safety, 32, 73-80.
10. Cullen, D.J., Sweitzer, B.J., Bates, D.W., Burdick, E., Edmondson, A. & Leape, L.L. (1997) Preventable adverse drug events in hospitalized patients: a comparative study of intensive care units and general care units. Critical Care Medicine, 25, 1289-1297.
11. Dalton, J., Ippolito, C., Poncet, I. & Rossini, S. (2005) White paper by Intel Corp, Authentica, Cisco Systems and San Raffaele Hospital. Sept 2005. WWW document. Available at: http://www.cisco. com/global/IT/ local_offices/case_history/rfid_in_blood_transfusions_final.pdf.
12. Dzik, W.H. (2003) Emily Cooley Lecture 2002: transfusion safety in the hospital. Transfusion, 43, 1190-1199.
13. Dzik, W.H. (2005) Technology for enhanced transfusion safety. American Society of Hematology. Education Program, 476-482.
14. Dzik, W.H., Corwin, H., Goodnough, L.T., Higgins, M., Kaplan, H., Murphy, M., Ness, P. Shulman, I.A. & Yomtovian, R. (2003a) Patient safety and blood transfusion: new solutions. Transfusion Medicine Reviews, 17, 169-180.
15. Dzik, W.H., Murphy, M.F., Andreu, G., Heddle, N., Hogman, C., Kekomaki, R., Murphy, S., Shimizu, M., Smit-Sibinga, C.T.and the Biomedical Excellence for Safer Transfusion (BEST) Working Party of the International Society for Blood Transfusion. (2003b) An international study of the performance of patient sample collection. Vox Sanguinis, 85, 40-47.
16. Dzik, S., Patterson, L. & Chapman, C. (2004) International forum: transfusion safety in the hospital. Vox Sanguinis, 87, 48-62.
17. Dzik, W.H., Wiklund, R., Sunder, N. & Freidberg, A. (2005) Radiofrequency (RF) tags for improved patient identification and safety: development of a prototype system. (abstract). Transfusion, 45 (Suppl. 1), 143A.
18. Etchells, T.A. & Harrison, M.J. (2006) Orthogonal search-based rule extraction for modeling the decision to transfuse. Anesthesia, 61, 335-338.
19. Health Grades, Inc. (2006) Third Annual Patient Safety in American Hospitals Study. Health Grades, Inc., Golden, CO, USA. Accessed July 2006 at: http://www.healthgrades.com/media/dms/pdf/Patient SafetyInAmericanHospitalsStudy2006.pdf.
20. Hillmann, J.M. & Given, R.S. (2005) Hospital implementation of computerized provider order entry systems: results from the 2003 leap from group quality and safety survey. Journal of Healthcare Information Management, 19, 55-65.
21. Kaplan, H.S. (2005) Getting the right blood to the right patient: the contribution of near-miss event reporting and barrier analysis. Transfusion Clinique et Biologique, 2, 380-384.
22. Kohn, L.T., Corrigan, J.M. & Donaldson, M.S.(Institute of Medicine) (2000) To Err is Human: Building a Safer Health System. National Academy Press, Washington, DC.
23. Koppel, R., Metlay, J.P., Cohen, A., Abaluck, B., Localio, A.R., Kimmel, S.E. & Strom, B.L. (2005) Role of computerized physician order entry systems in facilitating medication errors. Journal of the American Medical Association, 293, 1197-1203.
24. Kucher, N., Koo, S., Quiroz, R., Cooper, J.M., Paterno, M.D., Soukonnikov, B. & Goldhaber, S.Z. (2005) Electronic alerts to prevent venous thromboembolism among hospitalized patients. New England Journal of Medicine, 352, 1034-1036.
25. Linden, J.V., Wagner, K., Voytovich, A.E. & Sheehan, J. (2000) Transfusion errors in New York State: an analysis of 10 years' experience. Transfusion, 40, 1207-1213.
26. Lumadue, J.A., Boyd, J.S. & Ness, P.M. (1997) Adherence to a strict specimen-labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens. Transfusion, 37, 1169-1172.
27. Miller, K.A. (2000) Transfusion Errors. Q Probe09. Q-Probes. College of American Pathologists, Northfield, IL.
28. Murphy, M.F. & Kay, J.D. (2004) Barcode identification for transfusion safety. Current Opinion in Hematology, 5, 334-338.
29. Murphy, M.F., Steam, B.E. & Dzik, W.H. (2004) Current performance of patient sample collection in the UK. Transfusion Medicine, 14, 113-121.
30. Nichols, J.H., Bartholomew, C., Brunton, M., Clintron, C., Elliott, S., McGirr, J., Morsi, D., Scott, S., Seipel, J. & Sinha, D. (2004) Reducing medical errors through barcoding at the point of care. Clinical Leadership Management Review, 18, 328-334.
31. Novis, D.A., Miller, K.A., Howanitz, P.J., Renner, S.W. & Walsh, M.K. (2003) Audit of transfusion procedures in 660 hospitals. Archives of Pathology and Laboratory Medicine, 127, 541-548.
32. Peteja, J., Andersson, S. & Syrjala, M. (2004) A simple automatized audit system for following and managing practices of platelet and plasma transfusions in a neonatal intensive care unit. Transfusion Medicine, 14, 281-288.
33. Poon, E.G., Cina, J.L., Churchill, W., Patel, W., Featherstone, E., Rothschild, J.M., Keohane, C.A., Whittemore, A.D., Bates, D.W. & Gandhi, T.K. (2006) Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in pharmacy. Annals of Internal Medicine, 145, 426-434.
34. Porcella, A. & Walker, K. (2005) Patient safety with blood products administration using wireless and bar-code technology. AMIA Annual Symposium Proceedings, 614-618.
35. Robillard, P., Nawej, K.I. & Jochem, K. (2004) The Quebec hemovigilance system: description and results from the first two years. Transfusion and Apheresis Science, 31, 111-122.
36. Rothschild, J.M., Landrigan, C.P., Cronin, J.W., Kaushall, R., Lockley, S.W., Burdick, E., Stone, P.H., Lilly, C.M., Katz, J.T., Czeisler, C.A. & Bates, D.W. (2005a). The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Critical Care Medicine, 33, 1694-1700.
37. Rothschild, J.M., Keohane, C.A., Cook, E.F., Oray, E.J., Burdick, E., Thompson, S., Hayes, J. & Bates, D.W. (2005b) A controlled trial of smart infusion pumps to improve medication safety in critically ill patient. Critical Care Medicine, 33, 533-540.
38. Sandler, S.G., Langeberg, A. & Dohnalek, L. (2005) Bar code technology improves positive identification and transfusion safety. Developments in Biologicals (Basel), 120, 19-24.
39. Sazama, K. (1990) Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion, 30, 583-590.
40. Sazama, K. (2003) Transfusion errors: scope of the problem, consequences, and solutions. Current Hematology Reports, 2, 518-521.
41. Smith, M.J., Stiefel, M.F., Magge, S., Frangos, S., Bloom, S., Gracias, V. & Le Roux, P.D. (2005) Packed red blood cell transfusion increases local cerebral oxygenation. Critical Care Medicine, 33, 1104-1108.
42. Suttner, S., Piper, S.N., Kumle, B., Lang, K., Rohm, K.D., Isgro, F. & Boldt, J. (2004) The influence of allogeneic red blood cell transfusion compared with 100% oxygen ventilation on systemic oxygen transport and skeletal muscle oxygen tension after cardiac surgery. Anesthesia and Analgesia, 99, 2-11.
43. Tinmouth, A., Macdougall, L., Fergusson, D., Amin, M., Graham, I.D., Hebert, P.C. & Wilson, K. (2005) Reducing the amount of blood transfused: a systematic review of behavioral interventions to change physicians' transfusion practices. Archives of Internal Medicine, 165, 845-852.