Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
Department of Medicine, McMaster University, Hamilton, ON, Canada.
Transfus Med Rev. 2019 Apr;33(2):78-83. doi: 10.1016/j.tmrv.2018.11.004. Epub 2018 Dec 6.
The transfusion chain is susceptible to error at every step. Accurate patient registration is a key first step that links a patient with their historical medical profile, yet patient registration is marked by its own challenges. Registration errors are deviations from standard operating procedures that occur during the process of patient registration. A frequent consequence of registration errors is the obfuscation of historical information and patient misidentification. Through duplicate registrations, patient information can be spread across multiple records and through hybrid registrations information from multiple patients can be combined into a single record. Patients with the same core identifiers, and the misuse of health insurance information also pose a threat to accurate registration. In the context of transfusion, this can lead to ABO discrepancies, failing to match for previously identified alloantibodies, and redundant serological investigations. Other consequences include missed billing opportunities and the inadvertent sharing of medical information. Reducing the occurrence of registration errors can be achieved through a multifaceted approach combining targeted educational efforts with technological improvements to the registration system. A recent development being the use of biometric identifiers. Despite their frequency, published reports on the occurrence and underlying cause of registration errors are rare. Most reports are found within articles on general medical errors or misidentification events and consequently, the true rate of registration errors among health information systems is not known. Here we summarize literature pertaining to how and why registration errors occur and their implications in the context of blood transfusion.
输血链在每个环节都容易出错。准确的患者登记是将患者与其历史医疗档案联系起来的关键第一步，但患者登记本身也存在挑战。登记错误是指在患者登记过程中偏离标准操作程序的情况。登记错误的一个常见后果是混淆历史信息和患者身份识别错误。通过重复登记，患者信息可能会分散在多个记录中，通过混合登记，多个患者的信息可以合并到一个记录中。具有相同核心标识符的患者以及滥用健康保险信息也对准确登记构成威胁。在输血方面，这可能导致 ABO 差异，无法匹配先前确定的同种抗体，以及重复进行血清学检查。其他后果包括错过计费机会和无意中共享医疗信息。通过结合有针对性的教育努力和对登记系统的技术改进，采用多方面的方法可以减少登记错误的发生。最近的一个发展是使用生物识别标识符。尽管登记错误很常见，但关于其发生和根本原因的已发表报告却很少。大多数报告都在关于一般医疗错误或身份识别错误的文章中找到，因此，不知道健康信息系统中登记错误的真实发生率。在这里，我们总结了与登记错误如何发生以及它们在输血背景下的影响有关的文献。
