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PSNet: Patient Safety Network
Journal Article
Study

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

Hensley NB, Koch CG, Pronovost PJ, et al. Joint Commission journal on quality and patient safety. 2019;45:190-198.

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.