基于计算机条形码的血液识别系统与输血差错和险些差错。

Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors.

机构信息

Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA.

出版信息

Mayo Clin Proc. 2013 Apr;88(4):354-9. doi: 10.1016/j.mayocp.2012.12.010.

DOI:10.1016/j.mayocp.2012.12.010

PMID:23541010

Abstract

OBJECTIVE

To determine whether the use of a computerized bar code-based blood identification system resulted in a reduction in transfusion errors or near-miss transfusion episodes.

PATIENTS AND METHODS

Our institution instituted a computerized bar code-based blood identification system in October 2006. After institutional review board approval, we performed a retrospective study of transfusion errors from January 1, 2002, through December 31, 2005, and from January 1, 2007, through December 31, 2010.

RESULTS

A total of 388,837 U were transfused during the 2002-2005 period. There were 6 misidentification episodes of a blood product being transfused to the wrong patient during that period (incidence of 1 in 64,806 U or 1.5 per 100,000 transfusions; 95% CI, 0.6-3.3 per 100,000 transfusions). There was 1 reported near-miss transfusion episode (incidence of 0.3 per 100,000 transfusions; 95% CI, <0.1-1.4 per 100,000 transfusions). A total of 304,136 U were transfused during the 2007-2010 period. There was 1 misidentification episode of a blood product transfused to the wrong patient during that period when the blood bag and patient's armband were scanned after starting to transfuse the unit (incidence of 1 in 304,136 U or 0.3 per 100,000 transfusions; 95% CI, <0.1-1.8 per 100,000 transfusions; P=.14). There were 34 reported near-miss transfusion errors (incidence of 11.2 per 100,000 transfusions; 95% CI, 7.7-15.6 per 100,000 transfusions; P<.001).

CONCLUSION

Institution of a computerized bar code-based blood identification system was associated with a large increase in discovered near-miss events.

摘要

目的

确定使用基于计算机条码的血液识别系统是否会减少输血错误或接近输血错误的发生。

方法

我们的机构于 2006 年 10 月引入了基于计算机条码的血液识别系统。在机构审查委员会批准后，我们对 2002 年 1 月 1 日至 2005 年 12 月 31 日和 2007 年 1 月 1 日至 2010 年 12 月 31 日期间的输血错误进行了回顾性研究。

结果

在 2002-2005 年期间共输注了 388837U。在此期间，有 6 次血产品被输注给错误患者的身份识别错误事件（发生率为每 64806U 发生 1 次，或每 100000 次输血 1.5 次；95%CI，每 100000 次输血 0.6-3.3 次）。有 1 次报告的接近输血错误事件（发生率为每 100000 次输血 0.3 次；95%CI，<0.1-1.4 次/100000 次输血）。在 2007-2010 年期间共输注了 304136U。在此期间，当开始输注单位时扫描血袋和患者臂带后，有 1 次血产品被输注给错误患者的身份识别错误事件（发生率为每 304136U 发生 1 次，或每 100000 次输血 0.3 次；95%CI，<0.1-1.8 次/100000 次输血；P=0.14）。有 34 次报告的接近输血错误（发生率为每 100000 次输血 11.2 次；95%CI，每 100000 次输血 7.7-15.6 次；P<.001）。