PREVENTIVE MEASURES FOR THE IMPROVEMENT OF THE SAFETY OF BLOOD TRANSFUSION AND VIRTUAL TRANSFUSION LABORATORY
Abstract
Background. Even though blood transfusion is a relatively safe form of therapy, because of the eventual administrative errors in the transfusion chain between the blood donor and the recipient of blood, transfusion errors still occur. Therefore, it is imperative to ensure an utmost extent of safety and reliability of all transfusion related procedures. The safety of blood transfusion can be improved by preventive actions, i.e. implementation of the total quality management concept, haemovigilance and virtual transfusion laboratory. In the resulting system, the information web, robotics, computer sciences and communication technologies ensure safe and reliable identification of the patients, blood donors, corresponding test samples and blood products. Apart form this; the modern technologies enable the automation of laboratory testing, the integrity of laboratory results and enable an optimal use of blood.
Conclusions. For an improved transfusion safety in Slovenia, adoption of corresponding prevention as well as haemovigilance is necessary. Identification errors can be prevented by implementation of the wristbands systems with the code bars for the tagging of the patient and his biological samples, whereas the administrative errors in the blood bank and transfusion laboratory can be prevented by implementation of information systems and automation.
We assume that the virtual transfusion laboratory will become an integral part of the new Slovenian transfusion web and will speed up, unify and simplify today’s methods of ordering and administering blood products. To the attending physician, it will enable the choice of optimal transfusion therapy schedule and at the same time, it will enable the supervision of individual orders, deviations and indications, all of which is needed in order to analyse and improve the quality and the costs of the treatment. These services represent the first obligatory step for the modernisation of the transfusion medicine and accordingly, of the Slovenian health system in sense of the total quality assurance.
Downloads
References
Vengelen-Tyler V et al. Technical manual. 13th ed. Bethesda: American Association of Blood Banks, 1999.
Anon. Guidelines for quality assurance programmes for blood transfusion services. Transfusion Today 1996; 2: 3–6.
Flynn JC Jr. Essentials of immunohematology. Philadelphia, London, Toronto, Montreal, Sydney, Tokyo: W. B. Saunders Company, A Division of Harcourt Brace & Company, 1998.
Linden JV. Errors in transfusion medicine. Scope of the problem. Arch Pathol Lab Med 1999; 123: 563–5.
Shulman IA, Saxena S, Ramer L. Assessing blood administering practices. Arch Pathol Lab Med 1999; 123: 595–8.
Anon. Guide to the preparation, use and quality assurance of blood components. 6th ed. Geneve: Council of Europe publishing, 2000.
Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990; 30: 583–90.
Mercurilali F, Inghilleri G, Colotti MT, Podico M et al. One-year use of the Bloodloc system in an orthopedic institute. Transfus Clin Biol 1994; 1: 227–30.
Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York State: an analysis of 10 years’ experience. Transfusion 2000; 40: 1207–13.
Ibojie J, Urbaniak SJ. Comparing near misses with actual mistransfusion events: a more accurate reflection of transfusion errors. Br J Haematol 2000; 108: 458–60.
Baele PL, De B, Deneys V, Dupont E et al. Bedside transfusion errors. A prospective survey by the Belgium SAnGUIS Group. Vox Sang 1994; 66: 117–21.
Cox C, Enno A, Deveridge S, Seldon M et al. Remote electronic blood release system. Transfusion 1997; 37: 960–4.
Sharma RR, Kumar S, Agnihotri SK. Sources of preventable errors related to transfusion. Vox Sang 2001; 81: 37–41.
Goldman M, Remy P, Trepanier A, Decary F. Autologous donation error rates in Canada. Transfusion 1997; 37: 523–7.
Linden JV, Schmidt GB. An overview of state efforts to improve transfusion medicine. The New York state model. Arch Pathol Lab Med 1999; 123: 482–5.
Anon. Standards for blood banks and transfusion services. 18th ed. Bethesda: American Association of Blood Banks, 1997.
Anon. Pravilnik o dajanju človeške krvi, njenih sestavin in derivatov v promet. Ur. list SFRJ 35/89.
Anon. Zakon o preskrbi s krvjo. UL RS št. 52/00.
Priporočilo o pripravi, uporabi in zagotavljanju kakovosti komponent krvi. Prevod. Ljubljana: Zavod RS za transfuzijo krvi: Informacijsko dokumentacijski center Sveta Evrope pri Narodni in univerzitetni knjižnici, 2000.
Sibinga S. Total quality management in blood transfusion. Vox Sang 2000; 78: Suppl 2: 281–6.
Shulman IA, Lohr K, Derdiarian AK, Picukaric JM. Monitoring transfusionist practices: a strategy for improving transfusion safety. Transfusion 1994; 34: 11–5.
Battles JB, Kaplan HS, Van D, Shea CE. The attributes of medical eventreporting systems: experience with a prototype medical event-reporting system for transfusion medicine. Arch Pathol Lab Med 1998; 122: 231–8.
Debeir J, Noel L, Aullen J, Frette C, Sari F, Mai MP et al. The French haemovigilance system. Vox Sang 1999; 77: 77–81.
Noel L, Debeir J, Cosson A. The French haemovigilance system. Vox Sang 1998; 74: Suppl 2: 441–5.
Williamson LM. Systems contributing to the assurance of transfusion safety in the United Kingdom. Vox Sang 1999; 77: 82–7.
Williamson L, Cohen H, Love E, Jones H, Todd A, Soldan K. The serious hazards of transfusion (SHOT) initiative: the UK approach to haemovigilance. Vox Sang 2000; 78: Suppl 2: 291–5.
Menitove JE. Hemovigilance in the United States of America. Vox Sang 1998; 74: Suppl 2: 447–55.
Domanović D. Hemovigilanca. 3. podiplomski seminar. Zdravljenje s krvjo v kirurgiji. Zagotavljanje varnosti. Portorož, Slovenija, 14.–16. december 2000. Ljubljana: Klinični center – SPS Kirurške klinike, Zavod RS za transfuzijo krvi, European School of Transfusion Medicine, 2000: 80–6.
Dujardin PP, Salmi LR, Ingrand P. Errors in interpreting the pretransfusion bedside compatibility test: an experimental study. Vox Sang 2000; 78: 37–43.
Ingrand P, Surer P, Houssay D, Salmi LR. Reliability of the pretransfusion bedside compatibility test: association with transfusion practice and training. Transfusion 1998; 38: 1030–6.
Renner SW, Howanitz PJ, Bachner P. Wristband identification error reporting in 712 hospitals. A College of American Pathologists’ Q-Probes study of quality issues in transfusion practice. Arch Pathol Lab Med 1993; 117: 573–7.
Jensen NJ, Crosson JT. An automated system for bedside verification of the match between patient identification and blood unit identification. Transfusion 1996; 36: 216–21.
Lau FY, Wong R, Chui CH, Ng E, Cheng G. Improvement in transfusion safety using a specially designed transfusion wristband. Transfus Med 2000; 10: 121–4.
Shulman IA. The »virtual« transfusion service laboratory. Transfusion 1997; 37: 883–5.
Connelly DP, Willard KE, Hallgren JH, Sielaff BH. Closing the clinical laboratory testing loop with information technology. Am J Clin Pathol 1996; 105: 4 Suppl 1: S40–S47.
Potočnik M, Rožman P, Bricl I. Impact of new techniques on pretransfusion testing. Abstract. Infusionstherapie und Transfusionsmedizin 1997; 24: 256–6.
Potočnik M, Rožman P. Applicability of the gel test in urgent pretransfusion testing. Abstracts, 3rd Regional Congress, European Region. Praga, 1991. Praga: International Society of Blood Transfusion, 1991: 85–5.
Potočnik M, Rožman P, Bricl I. Computerised information system in the cross-matching for the patients with the low titre RBC antibodies. Abstract. Vox Sanguinis 1994; 67: S2: 10–0.
Chapman JF, Milkins C, Voak D. The computer crossmatch: a safe alternative to the serological crossmatch. Transfus Med 2000; 10: 251–6.
Connelly DP, Sielaff BH, Willard KE. The clinical workstation as a means of improving laboratory use. Clin Chim Acta 1996; 248: 51–64.
The Author transfers to the Publisher (Zdravniški vestnik/Slovenian Medical Journal) all economic copyrights following form Article 22 of the Slovene Copyright and Related Rights Act (ZASP), including the right of reproduction, the right of distribution, the rental right, the right of public performance, the right of public transmission, the right of public communication by means of phonograms and videograms, the right of public presentation, the right of broadcasting, the right of rebroadcasting, the right of secondary broadcasting, the right of communication to the public, the right of transformation, the right of audiovisual adaptation and all other rights of the author according to ZASP.
The aforementioned rights are transferred non-exclusively, for an unlimited number of editions, for the term of the statutory
The Author can make use of his work himself or transfer subjective rights to others only after 3 months from date of first publishing in the journal Zdravniški vestnik/Slovenian Medical Journal.
The Publisher (Zdravniški vestnik/Slovenian Medical Journal) has the right to transfer the rights, acquired parties without explicit consent of the Author.
The Author consents that the Article be published under the Creative Commons BY-NC 4.0 (attribution-non-commercial) or comparable licence.
