Pp blog final

UNTRUE BLOOD

Lily GonzalezVicky Yeh

History/Statistics of Blood Transfusions• Each year almost five million Americans need blood transfusions due

to illnesses such as anemia, surgeries and accidents.• Blood transfusions have been around for many years. In 1818, James

Blundell, a British obstetrician was the first to perform a successful transfusion of human blood.

• The first human blood transfusion in the United States (U.S.) was in 1795 given in Philadelphia. Between 1825 and 1830, he performed ten more successful transfusions.

• In 1926, the British Red Cross was the first blood transfusion service in the world.

• The first blood bank was established in 1932 in the U.S. In 1971 Hepatitis B surface antigen testing began in the United States. In 1985, HIV screening in blood transfusions began in the United States.

More StatisticsAllergic 1:500 3-4%

Febrile 1:1000-1:10,000 1-2%

TRALI (transfusion related acute long injury

1:5000-1: 100,000 rare

Hemolytic reaction(Fatal)

1:250,000-1: 600,000 Rare (50% are caused by clerical error)

(APHON , 2007)

• Fig. 1. Serious hazards of transfusions (U.K. cumulative data. GVHD=graft vs. host disease; TRALI= transfusion related acute lung injury)

FACTS• Fifteen million units of blood are donated each year in

the U.S. • Twenty nine million units of blood products are

transfused each year. Thirty eight thousand units of packed red blood cells are transfused each day.

• The risk of mistransfusion is at least 100 times greater than the risk of acquiring HIV, Hepatitic C virus ( ).

• 80 % of blood transfusion errors are shown to be related to either bedside errors and /or labeling errors.

• 13%of blood transfusion errors are linked to blood bank errors.

What’s the Problem?• Some of the human errors consist of;• Incorrect labeling of blood specimens from the patient at the bedside or

during printing of the labels of patients with similar names. • Detachment of labels may also result in errors in proper identification. • Improper bedside identification may also occur. • Other errors include rush situations such as stat orders either in trauma

or surgeries. • Mix up of blood products may occur during the storage process and

during the handling of multiple specimens simultaneously. • The most common human error is inadequate cross matching that occurs

at the blood bank .• According to a study by Sharma et al, 80 percent of blood transfusion

errors are shown to be related to either bedside errors and /or labeling errors.

• 13% of blood transfusion errors are linked to blood bank errors. Many facilities use barcodes to identify their patients to help reduce error rates.

Internal Assessment

Internal Assessment Findings• The results are as follows; 90% of the nurses replied yes to question

#1 due to the hectic nature of the hematology oncology unit. • 90% of the nurses also answered yes to question #2 regarding

mislabeling of blood lab specimens.• Reasons can be that many patients have similar last names which

can lead to easily confusing the names and picking the wrong addressograph.

• 50% of nurses stated that they did not do the bedside checks prior to administering.

• Sadly, bad habits such as these develop due to the familiarity of the patients on a hem/onc unit.

• 75% of the nurses stated that they were not as familiar with the exact causes of hemolytic reactions. 100% of the nurses replied yes to knowing the common signs and symptoms of a blood transfusion reaction.

Solution Radio Frequency Identification

• The goal is to improve the quality and safety of the blood transfusion process and

provide a high quality service with minimal risks to patients• RFID will improve the quality and safety of the blood transfusion process and

provide a high quality service with minimal risks to patients. • The RFID works by placing unique identifier microchips in the forms of

stickers on items such as blood bags, patient identification bracelets and any other equipment.

• RFID tags can be scanned and health information and identification can be accessed. The RFID would virtually eliminate all human errors in the blood transfusion process.

• Such errors are; mislabeling of blood specimens taken for the type and cross at the bedside, crosschecking of forms to the blood product prior to administering blood, mistakes that occur during cross matching in the blood bank (mixing up of blood samples due to handling of multiple specimens at once) and so forth.

•RFID RESEARCH• According to Fisher and Monahan, “ (RFID) is an emerging

technology that is rapidly becoming the standard for hospitals to track inventory, identify patients and manage personnel” (Fisher & Monahan, 2008).

• The article provides research information that was conducted from May, 2005 to August, 2006 in hospital settings in the Southwestern United States.

• Data was collected from hospital administrators, technical staff, physicians and nurses.

• The findings suggest that the RFID system offers great promise for increased efficiency and cost savings.

• RFID has the potential to provide more efficient processes resulting in saving time and money.

• RFID systems are also valued for their ability to collect data in real time.

Siemens RFID• Siemens RFID had proven to increase patient safety and decrease

production costs. • The Siemens RF 300 process to be highly flexible and facilitates the

manufacture of configurable products. Some of it favorable qualities include being rugged for all production tasks and maintenance free.

• Fast data transmission between reader/writer and tag (up to 8000 Bytes), and an easy integration in SIMATIC, PROFIBUS and PROFINENT.

• The Siemens RFID proves to have an especially interference proof data communication with high data security.

• The RFID system’s hardware include:1. transponder which is the RFID identification tag that has been

programmed with patient information2. scanning antenna which puts out radiofrequencies which is wireless

communication. 3. windows based software that compares data from the wristband to the

data stored in the RFID system

RFID TYPES

The Transition Phase• In services will be performed to familiarize staff

with the RFID system. These in services will include the following topics:

1. The need for RFID use in conjunction with the blood transfusion process

2. Information on RFID3. Pros and Cons of RFID4. Benefits to the hospital by implementations of

RFID 5. Emphasize the importance of RFID to improve

patient safety and confidentiality

Case Study• Case 5• Two patients with identical first and surnames but different dates

of birth underwent similar noncardiac vascular surgery on close dates. Preoperatively, patient A had undergone autologous blood donation. Patient B required postoperative blood transfusion. With no difference in name, the autologous blood of patient A was filed to patient B by a nurse on the ward. The attending physician checked the accompanying identification material, however, without paying attention to the dates of birth recorded on the patient’s chart and the form attached to the unit to be transfused. He did not deem these details very important because it was “just autologous blood.” For the same reason, he also refrained from pretransfusion ABO compatibility testing. After transfusion of the first 100 mL of red blood cells the patient developed acute hemolysis and shock. He died on the same day. The case went to court.

Go live• Once hospital staff has been in serviced and familiarized with

the product, the hospital will use a team approach for implementing RFID by forming project teams. The project teams will include members of vendors (Siemens), hospital medical staff, IT (information technology) unit and consultants.

• Superusers from each unit will go through extensive week long training on the RFID system.

• Then hospital wide training will begin:1. 8 hour days of educational training and practice. 2. Educational videos will be shown, 3. hands on training using the RFID system will be provided. 4. Internet tutorials will need to be completed by employees

to enforce the teaching of the use of RFIDs.

RFID in action

The reflection upon our errors gives us wisdom and

knowledge that leads to wise, life saving decisions.