Barcoding to Prevent Incorrect Blood Transfusions
An Analysis of Evidence Based Practice

Nursing 255

October 1, 2011
Abstract

In recent years, technology has advanced to heights that were previously unimagined. These advances have given us additional options to combat human errors that we have merely had to cope with in less technologically advanced times. As little as an ounce of the wrong blood during a transfusion can be fatal. Barcoding technology and other similar systems that reduce reliance on human data entry and double-checking have potential to greatly increase productivity and accuracy (Porcella & Walker, 2005). In fact, “Use of bar code technology for patient and product identification is not only a future requirement of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), but is also a major tool for error reduction. Wireless technology enables use of bar code equipment at the patient bedside, maximizing process efficiencies.” (Porcella & Walker, 2005) This paper reviews and analyzes the effects barcoding technology has had on the field of blood transfusions and patient safety as well as the resistance observed in clinical practices and the limitations on the technology due to cost of deployment.

Barcoding to Prevent Incorrect Blood Transfusions

An Analysis of Evidence Based Practice

On July 22, 2003 a technician at Inova Fairfax hospital went into a patients room to draw blood for a type and cross because the patient was scheduled for surgery the next day. Apparently checks weren’t completed correctly and the technician drew blood from the wrong patient. The next day the patient received two pints of the wrong blood during a bowel resection and the patient died after an acute hemolytic transfusion reaction (Goldstein, 2003).

“Transfusion errors are relatively rare, but they have proved difficult to eliminate and remain among the most formidable challenges for blood banks, hospitals and doctors, said Louis M. Katz, president of America's Blood Centers” (Goldstein, 2003) In 2010 there were only 40 transfusion related deaths and only 7 of which were hemolytic transfusion reactions (FDA, 2011). The Food and Drug Administration has reported a continual decrease in the risk concerning blood transfusions. In 2008, approximately 24 million units were transfused, while only 54 transfusion-related fatalities were reported (FDA, 2011).

While the risk for blood transfusion errors has decreased, our goal, however difficult, should be to reach no fatalities related to hospital errors for both blood transfusions as well as other aspects of patient care, most especially medication administration. We should also look at the possible reasons for that decrease in errors over the last 10 years. “Patient safety associated with the blood transfusion process has received considerable attention in recent years due to the propensity of transfusion errors to cause catastrophic morbidity or mortality. Error reductions are most likely to be obtained by a systems approach having the goals of reducing incomplete or erroneous identification of patients or blood products, simplifying processes, and obviating clerical or transcription errors” (Porcella & Walker, 2005)

“The Institute of Medicine Report stated that “as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors,” with an estimated 7,000 of these deaths related to medication errors. This bellwether report on medical errors and the need for enhanced patient safety indicated that many medication errors are not a result of individual performance but rather occur because providers fail to incorporate systems that could be designed to prevent such mishaps and tragedies.” (Perrin & Simpson, 2004) As a student who has had been assigned to clinicals at Inova Fairfax Hospital for multiple rotations, I can personally attest to the fact that full implementation of bar coding has not been completed. While the Inova care system has both the funds and possesses the technology for full implementation, nurses continue to resist the change. “Before the advent of automated systems, hospitals used myriad manual paper-intensive processes to order, track, and bill for supplies and medications. During the past few years, there has been increasing emphasis on integrating these activities by using information systems designed to automate order processing, data capture, and supply consumption for patient charging.” (Perrin & Simpson, 2004) The source of resistance is not easily identified. While nurses continue to rely on themselves to prevent errors, the hospital administration and health care providers have not required nurses to use the technology available. This is a failure on the part of both parties but ultimately the hospital administration and providers will be held accountable for not requiring the nurses to change their behavior. And while nurses will be held responsible for any errors they make, these errors are being proven as preventable. As nurses and administrators continues to resist change, the risk for malpractice lawsuits will continue to increase, putting pressure on insurance companies to raise premiums and further effecting the economy that administrators cite as the reason for being unable to afford implementing new and advancing technologies to prevent patient identification errors.

“Wireless technology enables use of bar code equipment at the patient bedside, maximizing process efficiencies.” (Porcella & Walker, 2005) Administrators are failing to realize the long-term benefits as well as consequences of their resistance to change. This may be due to the failure to properly integrate the systems when they were first conceived and made available. Bar code scanners are available in every department at Inova Fairfax that I have visited. Nurses are able to scan the patient’s id tags and then take vital signs by scanning the Dinamap or for the administration of medications by scanning the vial or package. This can also be used for blood administration and type and cross. I have personally observed the failure to use this technology lead to charting errors. And until hospital administration or perhaps JHACO begins to require this of nurses, errors will continue to occur.

While the most fatal of these errors is transfusing incompatible blood, which has decreased because of the use of technology, errors in medication administration and vital sign reporting are equally as important. Experiments have estimated that nurses are 30 times more likely to catch an identification error using the barcode system than with the manual system for blood administration. (Porcella & Walker, 2005) Statistics like this cannot be ignored any longer. Until a proper plan for integration is implemented and followed, resistance will continue. The longer this resistance to change continues, the more patients lives will be put at risk; a fact no person in the health care profession can support.

References

Perrin, R. A., & Simpson, N. (2004). Rfid and bar codes— critical importance in enhancing safe patient care. JHIM: Journal of Healthcare Information Management, 18(4), Retrieved from http://www.himss.org/content/files/jhim/18-4/focus3.pdf

(Perrin & Simpson, 2004)

Goldstein, A. (2003, August 29). Patient dies from blood mismatch. The Washington Post, p. B01. . Retrieved from http://www.washingtonpost.com/ac2/wp-dyn/A61670-2003Aug28?language=printer

(Goldstein, 2003)

Porcella, A., & Walker, K. (2005). Patient safety with blood products administration using wireless and bar-code technology. AMIA Annual Symposium Proceedings, 2005, 614-618. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1560432/

(Porcella & Walker, 2005)

FDA. U.S. Department of Health and Human Service, U.S. Food and Drug Administration. (2011). Fatalities reported to fda following blood collection and transfusion: annual summary for fiscal year 2010. Rockville, MD: Retrieved from http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/TransfusionDonationFatalities/ucm254802.htm

(FDA, 2011)