Dzik Walter H
Massachusetts General Hospital, Boston, MA 02114, USA.
Br J Haematol. 2007 Jan;136(2):181-90. doi: 10.1111/j.1365-2141.2006.06373.x. Epub 2006 Nov 8.
Hemovigilance programs from around the world document that the greatest risk to recipients of blood transfusion is human error, resulting in transfusion of the incorrect blood component. Errors in transfusion care have strong parallels with errors in medication administration. Errors often result from 'lapse' or 'slip' mistakes in which details of patient identification are overlooked. Three areas of transfusion are focal points for improved care: the labelling of the patient's pre-transfusion sample, the decision to transfuse and the final bedside check designed to prevent mis-transfusion. Both barcodes and radio-frequency identification technology, each ideally suited to matching alpha-numeric identifiers, are being implemented in order to improve performance sample labelling and the bedside check. The decision to transfuse should ultimately be enhanced through the use of nanotechnology sensors, computerised order entry and decision support systems. Obstacles to the deployment of new technology include resistance to change, confusion regarding the best technology, and uncertainty regarding the return-on-investment. By focusing on overall transfusion safety, deploying validated systems appropriate for both medication and blood administration, thoughtful integration of technology into bedside practice and demonstration of improved performance, the application of new technologies will improve care for patients in need of transfusion therapy.
世界各地的血液监测项目表明,输血接受者面临的最大风险是人为失误,导致输注错误的血液成分。输血护理中的失误与用药管理中的失误有很强的相似之处。失误通常是由于“失误”或“疏忽”造成的,即忽视了患者识别的细节。输血的三个领域是改善护理的重点:患者输血前样本的标签、输血决定以及旨在防止误输血的最终床边检查。条形码和射频识别技术都非常适合匹配字母数字标识符,目前正在实施这些技术以改善样本标签和床边检查的性能。输血决定最终应通过使用纳米技术传感器、计算机化医嘱录入和决策支持系统来加强。新技术应用的障碍包括对变革的抵制、对最佳技术的困惑以及对投资回报率的不确定性。通过关注整体输血安全、部署适用于用药和输血管理的经过验证的系统、将技术精心整合到床边实践中以及展示改进的性能,新技术的应用将改善需要输血治疗的患者的护理。