Technology for enhanced transfusion safety.

Abstract

Data from reporting systems around the world document that non-infectious hazards are the leading cause of serious morbidity or mortality resulting from blood transfusion. Among these non-infectious hazards, mis-transfusion represents the most frequently observed serious hazard and occurs at an estimated rate of 1 in 14,000 transfusions. Mis-transfusion events result from "lapse errors" (slip ups) rather than cognitive mistakes. Lapse errors are more likely to occur during repetitive tasks when individuals are distracted, rushed, or fatigued--conditions to which machines are not susceptible. The final bedside check and the collection of patient samples for pre-transfusion testing are key "error spots" and are candidates for new technology innovation. Existing technology includes non-computerized devices; bedside devices based on bar code technology; and the use of radiofrequency chips. Several commercial systems employing bar-code technology have reached clinical application or are undergoing refinement. Radiofrequency-based systems are on the near horizon. Nearly all systems begin with the application of machine-readable data to the patient's wristband. The third error spot--the decision to transfuse--will be a challenging area for future application of information technology. Computerized physician order-entry, decision support and ultimately active computer-based decision-making are expected to enhance transfusion decisions. Despite the explosive growth in information technology in modern society, healthcare has lagged behind many other sectors in the use of enhanced information technology. Studies are needed to identify which technologies improve patient outcomes. Healthcare workers, administrators, and regulators need to embrace the use of new technology in order to reduce errors and improve safety for patients.