Implementation of a two-specimen requirement for verification of ABO/Rh for blood transfusion

Transfusion

Volumn 49, Issue 7, 2009, Pages 1321-1328

  Goodnough, Lawrence T ^a   Viele, Maurene ^b   Fontaine, Magali J ^b   Jurado, Christine ^b   Stone, Nancy ^b   Quach, Peter ^b   Chua, Lee ^b   Chin, Mei Ling ^b   Scott, Robert ^b   Tokareva, Irina ^b   Tabb, Kevin ^b   Sharek, Paul J ^b  

^a STANFORD UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; BLOOD GROUP ABO SYSTEM; BLOOD GROUP TYPING; BLOOD SAMPLING; BLOOD TRANSFUSION; ERROR; HOSPITAL POLICY; HUMAN; PHLEBOTOMY;

ABO BLOOD-GROUP SYSTEM; BLOOD GROUPING AND CROSSMATCHING; BLOOD SPECIMEN COLLECTION; BLOOD TRANSFUSION; HUMANS; PATIENT IDENTIFICATION SYSTEMS; RH-HR BLOOD-GROUP SYSTEM;

EID: 67649973326     PISSN: 00411132     EISSN: 15372995     Source Type: Journal    
DOI: 10.1111/j.1537-2995.2009.02157.x     Document Type: Article

References (25)

1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC : National Academy Press 2000.
2. Williamson LM, Lowe S, Love EM, Cohen H, Soldan K, McClelland DB, Skacel P, Barbara JA. Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports. BMJ 1999 319 : 16 9.
3. Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990 30 : 583 90.
4. Linden JV, Paul B, Dressler KP. A report of 104 transfusion errors in New York State. Transfusion 1992 32 : 601 6.
5. Stainsby D. ABO incompatible transfusions - experience from the UK Serious Hazards of Transfusion (SHOT) scheme transfusions ABO incompatible. Transfus Clin Biol 2005 12 : 385 8.
6. Goodnough LT, Brecher ME, Kantor MH, Aubuchon JP. Transfusion medicine part 1: blood transfusion. N Engl J Med 1999 340 : 438 47.
7. Janatpour KA, Kalmin ND, Jensen HM, Holland PV. Clinical outcomes of ABO-incompatible RBC transfusions. Am J Clin Pathol 2008 129 : 276 81.
8. Sazama K. Transfusion errors: scope of the problem, consequences, and solutions. Curr Hematol Rep 2003 2 : 518 21.
9. The Joint Commission. National patient safety goals. Oakbrook Terrace (IL) : The Joint Commission 2003. Available from: http://www.jointcommission. org/PatientSafety/NationalPatientSafetyGoals/03-npsgs.htm
10. College of American Pathologists Commission on Laboratory Accreditation. Laboratory accreditation program transfusion medicine checklist. Northfield (IL) : College of American Pathologists Commission on Laboratory Accreditation 2006
11. Dzik W. New technology for transfusion safety. Br J Haematol 2006 136 : 181 90.
12. Centers for Medicare and Medicaid Services. Medicare takes new steps to help make your hospital stay safer. Baltimore (MD) : Centers for Medicare and Medicaid Services 2008 cited 2009 March 8]. Available from: http://www.cms.hhs. gov/apps/media/press/factsheet.asp?Counter=3227&intNumPerPage= 10&checkDate=&checkKey=&srchtype=1&numDays=3500&srchOpt= 0&srchData=&keywordtype=All&chkNewstype=6&intPage=&showAll= &pYear=&year=&desc=false&cboOrder=date
13. Serious reportable events in healthcare: a consensus report. Washington, DC : National Quality Forum 2002.
14. State of California - Health and Human Services Agency. Sacramento (CA) : California Department of Public Health 2007. Available from: http://www.cdph.ca.gov/certlic/facilities/documents/LNC-AFL-07-10.pdf
15. Wenz B, Mercuriali F, Aubuchon JP. Practical methods to improve transfusion safety by using novel blood unit and patient identification systems. Am J Clin Pathol 1997 107 : 512 16.
16. Figureosa PI, Ziman A, Wheeler C, Gornbein J, Monson M, Calhoun L. Nearly two decades using the check-type to prevent ABO incompatible transfusions: one institution's experience. Am J Clin Pathol 2006 126 : 422 6.
17. Dzik WH, Murphy MF, Andreu G, Heddle N, Hogman C, Kekomaki R, Murphy S, Shimizu M, Smit-Sibinga CT the Biomedical Excellence for Safer Transfusion (BEST) working party of the International Society for Blood Transfusion. An international study of the performance of sample collection from patients. Vox Sang 2003 85 : 40 7.
18. McClelland DB, Phillips P. Errors in blood transfusion in Britain: survey of hospital haematology departments. BMJ 1994 308 : 1205 6.
19. Lumadue JA, Boyd JS, Ness PM. Adherence to a strict specimen-labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens. Transfusion 1997 37 : 1169 72.
20. Murphy MF, Stearn BE, Dzik WH. Current performance of patient sample collection in the UK. Transfus Med 2004 14 : 113 21.
21. Chiaroni J, Legrand D, Dettori I, Ferrara V. Analysis of ABO discrepancies occurring in 35 French hospitals. Transfusion 2004 44 : 860 4.
22. Kaplan HS. Getting the right blood to the right patient: the contribution of near-miss event reporting and barrier analysis. Transfus Clin Biol 2005 12 : 380 4.
23. Quillen K, Murphy K. Quality improvement to decrease specimen mislabeling in transfusion medicine. Arch Pathol Lab Med 2006 130 : 1196 8.
24. Miyata S, Kawai T, Yamamoto S, Takada M, Iwatani Y, Uchida O, Imanaka H, Sase K, Yagihara T, Kuro M. Network computer-assisted transfusion-management system for accurate blood component. Recipient identification at the bedside. Transfusion 2004 44 : 364 72.
25. Ahrens N, Pruss A, Kieswetter H, Salama A. Failure of bedside ABO testing is still the most common cause of incorrect blood transfusion in the barcode era. Transfus Apher Sci 2005 33 : 25 9.