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.
S Narayan, ed. Manchester, UK: Serious Hazards of Transfusion (SHOT) Steering Group; 2021. ISBN: 9781999596835.
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.
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.
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.
Snijders C, van Lingen RA, Klip H, et al. Arch Dis Child Fetal Neonatal Ed. 2009;94:F210-5.
Incident reporting systems are one mechanism for hospitals to both identify and potentially prevent adverse events, although they have frequently failed to meet those expectations. This study describes findings from a voluntary system that produced a significant increase in reported neonatal events, many of which were associated with patient morbidity.
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.
Following spinal surgeries, two different patients developed tachycardia, hypotension, and hypoxia due to sepsis. Given the similarity in clinical course, the hospital investigated and found that both patients had received platelets contaminated with Staphylococcus aureus.
The researchers analyzed transfusion-related near-miss data and found that near misses occur more frequently than adverse events causing harm. They conclude that near-miss data are a useful tool for identifying human and system failures and targeting improvements.
Rana R, Afessa B, Keegan MT, et al. Crit Care Med. 2006;34:1892-7.
Using a computerized provider order entry (CPOE) system, the investigators developed an evidence-based protocol for red cell transfusion and found that it reduced inappropriate transfusions over a 3-month test period.
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