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- Wrong Patient
Journal Article > Study
Kaufman RM, Dinh A, Cohn CS, et al; BEST Collaborative. Transfusion. 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.
Journal Article > Review
Cohen R, Ning S, Yan MTS, Callum J. 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.
Journal Article > Study
The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.
Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.
Errors at the administration stage are common for intravenous medications. Programmable or smart infusion pumps are widely used as a means of preventing such errors. However, prior studies have found that smart pumps alone may not significantly reduce errors, as they do not eliminate wrong-patient errors and may be prone to workarounds. This study compared three types of pumps—traditional pumps, smart pumps, and smart pumps combined with bar-code technology—in a simulated inpatient unit. The results indicate that smart pumps may reduce administration errors when combined with bar-coding or when only "hard" (unchangeable) dosing limits are used. Ultimately, creation of a "closed-loop" system that integrates technological solutions to prescription and administration errors represents the optimal solution for eliminating medication errors.