Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.

Nadia B Hensley; Colleen G Koch; Peter Pronovost; Bommy Hong Mershon; Joan Boyd; Susan Franklin; Dana Moore; Kristen Sheridan; Anne Steele; Tracey L Stierer

Study

Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.

January 9, 2019

Hensley NB, Koch CG, Pronovost P, et al. Jt Comm J Qual Patient Saf. 2019;45(3):190-198.

View more articles from the same authors.

Following a sentinel wrong-patient event, a multidisciplinary quality improvement team worked to enhance the safety of blood transfusion. The authors report significant improvement in protocol adherence following institution of barcoding and auditing via the electronic health record.

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Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.

Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart

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