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.
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.
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.
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.
Rice-Townsend S, Hall M, Jenkins KJ, et al. J Pediatr Surg. 2010;45:1126-36.
This study sought to characterize the incidence and types of adverse events in pediatric surgery patients, using measures (the National Surgical Quality Improvement Program and the AHRQ Patient Safety Indicators) originally developed for identifying adverse events in adults. The authors argue that applying adult measures to a pediatric population overestimates the incidence of adverse events.
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.
Levtzion-Korach O, Alcalai H, Orav EJ, et al. J Patient Saf. 2009;52:9-15.
The limitations of standard incident reporting systems have been well documented. Although ubiquitous and relatively easy to use, such systems detect only a fraction of adverse events, are underused by physicians, and yield data that often are not analyzed or disseminated promptly. This analysis of data from a commercial, web-based system at an academic hospital confirms some prior concerns, but the authors were able to demonstrate that rapid review of reports resulted in specific system changes to improve workflow and safety. A prior article presented a framework for using incident reporting data to improve patient safety.
A centralized transfusion service maintains transfusion records for 16 hospitals in the Pittsburgh area. This study found that the centralized system prevented several instances of transfusion errors due to incorrectly collected blood specimens.
Anderson HJ. Health Data Manag. 2009;17:18-20, 22, 24 passim.
Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE) systems could reduce medical errors, a mere 8% of hospitals use the system and fewer implement it effectively, according to the Leapfrog Group CPOE evaluation tool.