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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 63 Results
Uramatsu M, Maeda H, Mishima S, et al. J Cardiothorac Surg. 2022;17:182.
Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.
S Narayan, ed. Manchester, UK: Serious Hazards of Transfusion (SHOT) Steering Group; 2022. ISBN: 9781999596842.
Although errors in the blood transfusion process are rare, they can be harmful. This annual report provides an analysis of transfusion-related errors reported to a national improvement program in the United Kingdom. The 2020 report recommends enhancing use of information technology and a focus on delay reduction as targets for mistake prevention. Previous reports in the series are available.
Dunbar NM, Kaufman RM. Transfusion (Paris). 2022;62:44-50.
Wrong blood in tube (WBIT) errors can be classified as intended patient drawn/wrong label applied or wrong patient/intended label applied. In this international study, errors were divided almost evenly between the two types and most were a combination of protocol violations (e.g. technology not used or not used appropriately) and slips/lapses (e.g., registration errors). Additional contributory factors and recommendations for improvement are also discussed.

Irvine, CA: The Patient Safety Movement Foundation; 2022.

Blood transfusion mistakes can result in severe adverse events. This report shares successful strategies to reduce transfusion process errors. The document highlights patient assessment, process standardization, and cross-disciplinary team building as steps toward improving transfusion safety.
Duzyj CM, Boyle C, Mahoney K, et al. Am J Perinatol. 2021;38:1281-1288.
Pregnancy and childbirth are recognized as high-risk activities for both the pregnant person and infant. This article describes the implementation of a postpartum hemorrhage patient safety bundle. Successes, challenges and recommendations for implementation are included.
Dunbar NM, Delaney M, Murphy MF, et al. Transfusion (Paris). 2021;61:2601-2610.
Transfusion errors can have serious consequences. This study compared wrong blood in tube (WBIT) errors in 9 countries across three settings: emergency department, inpatient, and outpatient. Results show emergency department WBIT errors were significantly higher in emergency departments, and that electronic positive patient identification (ePPID) significantly reduced WBIT errors in the emergency department, but not in inpatient or outpatient wards.
Sharp R, Turner L, Altschwager J, et al. J Clin Nurs. 2021;30:1751-1759.
Safety in home health care delivery is receiving increasing attention. This retrospective cohort study found that patients with medically stable, chronic conditions undergoing blood transfusion in a home setting provided by a nurse-led service experienced low rates of adverse events.
Vijenthira S, Armali C, Downie H, et al. Vox Sang. 2021;116:225-233.
Transfusion errors can have serious consequences. This retrospective analysis used a Canadian national database to characterize patient registration-related errors in the blood transfusion process. Findings indicate that registration errors most commonly occur in outpatient areas and emergency departments and can lead to delays in transfusion.
Vanneman MW, Balakrishna A, Lang AL, et al. Anesth Analg. 2020;131:1217-1227.
Transfusion errors due to patient misidentification can have serious consequences. This article describes the implementation of an automated, electronic barcode scanner system to improve pretransfusion verification and documentation. Over two years, the system improved documentation compliance and averted transfusion of mismatched blood products in 20 patients.  
Vossoughi S, Perez G, Whitaker BI, et al. Transfusion (Paris). 2019;59:2827-2832.
This analysis of transfusion-related safety incident reports found that such events were more commonly reported for pediatric compared to adult patients. This finding could reflect differences in reporting practices or underlying transfusion safety differences. The authors call for continued attention to transfusion safety.
WebM&M Case July 2, 2019
First admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding, a woman (G5 P2 A2) received 4 units of packed red blood cells and 2 doses of iron injections. She was discharged after 3 days with an improved hemoglobin level. At 35 weeks, she was admitted for an elective cesarean delivery. Intraoperatively, an upper uterine segment incision was made and the newborn was delivered in good condition. Immediately after, a subtotal hysterectomy was performed. The anesthesiologist noted that the patient was hypotensive; blood was transfused.
Kaufman RM, Dinh A, Cohn CS, et al. Transfusion (Paris). 2019;59:972-980.
Wrong-patient errors in blood transfusion can lead to serious patient harm. Research has shown that use of barcodes to ensure correct patient identification can reduce medication errors, but less is known about barcoding in transfusion management. This pre–post study examined the impact of barcode labeling on the rate of wrong blood in tube errors. Investigators found that use of barcoding improved the accuracy of labels on blood samples and samples that had even minor labeling errors had an increased chance of misidentifying the patient. The authors conclude that the results support the use of barcoding and the exclusion of blood samples with even minor labeling errors in order to ensure safe blood transfusion. An accompanying editorial delineates the complex workflow, hardware, and software required to implement barcoding for transfusion. A past WebM&M commentary discussed an incident involving a mislabeled blood specimen.
Cohen R, Ning S, Yan MTS, et al. Transfus Med Rev. 2019;33:78-83.
Inaccurate patient registration can result in information gaps that contribute to delay, misunderstandings, and harm. This review discusses registration errors in the blood transfusion process. The authors discuss how problems can occur during various stages in the transfusion process and result in blood-type discrepancies. They suggest improved reporting of identification mistakes and use of photo identification tools as strategies to prevent patient harm associated with registration errors.
Najafpour Z, Hasoumi M, Behzadi F, et al. BMC Health Serv Res. 2017;17:453.
Failure mode and effect analysis (FMEA) is a tool that facilitates prospective risk assessment and is frequently used to assess the risk of various processes in health care. The authors describe the use of FMEA at a single institution to improve the safety of the blood transfusion process.
WebM&M Case September 1, 2017
An older man with Crohn disease was admitted for abdominal pain and high stool output from his ileostomy. Despite blood passing from his ostomy and a falling hemoglobin level, the patient was not given a timely blood transfusion.
Clifford SP, Mick PB, Derhake BM. J Investig Med High Impact Case Rep. 2016;4:2324709616647746.
Transfusion errors can have serious consequences. This case analysis discusses a wrong-patient transfusion error in a hospital's emergency room and reviews findings of the subsequent root cause analysis, which determined training weaknesses, time pressures, and distractions within the team due to the chaotic nature of trauma care.
Dunbar NM, Szczepiorkowski ZM. Curr Opin Hematol. 2014;21:515-20.
Mistakes during blood transfusion can contribute to patient harm. This review discusses the use of health information technology, such as computerized provider order entry and clinical decision support systems, in transfusion medicine to enhance reliability of ordering practices and enable monitoring of adherence.
Maskens C, Downie H, Wendt A, et al. Transfusion (Paris). 2014;54:66-73; quiz 65.
In this study, the vast majority of transfusion-related patient harm was due to blood products ordered inappropriately outside of hospital guidelines. On the laboratory side, the most serious threat to patient safety was mislabeled blood samples.