Mercurilali F, Inghilleri G, Colotti M T, Podico M, Biffi E, Farè M, Vinci A, Scalamogna R
Centro Trasfusionale, Istituto Ortopedico G. Pini, Milano, Italie.
Transfus Clin Biol. 1994;1(3):227-30. doi: 10.1016/s1246-7820(05)80033-3.
Human error in patient or specimen identification due to fatigue, stress and lack of attention by technologists, nurses, interns, and physicians, can cause routinely safety procedures to be circumvented. Clerical errors may occur during the specimen collection, the issue of blood unit and the transfusion of blood. The introduction in an increasing number of hospital of preoperative autologous blood donation programs further increases the chance of error, because a single patient can predeposit multiple units of blood. In this cases there is a greater commitment not only to transfuse any blood unit that is ABO compatible but to transfuse the specific units the patient previously donated for his own use. Human error has been recognized as a significant cause of transfusion-associated fatalities. The persistence of the frequency and type of errors observed in spite of extensive efforts to eradicate them, suggests that errors are inevitable as long as large number of repetitive procedures are performed unless major system changes are adopted. A system (Bloodloc System) that physically prevents the possibility of error was adopted since January 1993 and cuncurrently a quality improvement program (QI) was implemented specifically designed to monitor: 1. the absence of the code on the blood samples, 2. the blood bank error in setting the Bloodloc, 3. the misidentification of blood samples, 4. any attempt to transfuse the wrong blood unit, 5. any attempt to transfuse, the wrong patients.
4895 blood units (2469 autologous and 2426 allogeneic units) were transfused to 1478 patients (849 predeposited an average of 3.3 +/- 2.0 units). The methodological errors (absence of three-letter code on the patient's specimen tube, wrong transcription of the code on the blood sample, wrong setting of the Bloodloc in the blood bank)--41 cases--were limited at the first four months of implementation of the system. In the same period however have been reported 3 potentially fatal errors which have been avoided by the Bloodloc. Two cases of misidentification of blood samples at the moment of the specimen collection, and one attempt to transfuse the wrong units to the wrong patients.
The Bloodloc system is effective in preventing potential transfusion-associated fatalities caused by units or recipients misidentification.
由于技术人员、护士、实习生和医生疲劳、压力和注意力不集中导致患者或标本识别中的人为错误，可能会导致常规安全程序被规避。在标本采集、血液单位发放和输血过程中可能会出现文书错误。越来越多的医院引入术前自体献血计划进一步增加了出错的几率，因为单个患者可以预先储存多个单位的血液。在这种情况下，不仅要输注任何ABO相容的血液单位，而且要输注患者先前为自己储存的特定单位的血液，这需要更大的责任心。人为错误已被确认为输血相关死亡的一个重要原因。尽管为消除错误付出了巨大努力，但观察到的错误频率和类型仍然持续存在，这表明只要进行大量重复性程序，除非采用重大系统变革，否则错误是不可避免的。自1993年1月起采用了一种从物理上防止出错可能性的系统（Bloodloc系统），目前实施了一项质量改进计划（QI），专门用于监测：1.血样上没有代码；2.血库设置Bloodloc时的错误；3.血样的错误识别；4.任何输注错误血液单位的企图；5.任何输注错误患者的企图。
向1478名患者输注了4895个血液单位（2469个自体单位和2426个异体单位）（849名患者预先储存了平均3.3±2.0个单位）。方法学错误（患者标本管上没有三个字母的代码、血样上代码的错误转录、血库中Bloodloc的错误设置）——41例——在系统实施的前四个月受到限制。然而，在同一时期报告了3起潜在的致命错误，这些错误已被Bloodloc避免。两例标本采集时血样的错误识别，以及一例向错误患者输注错误单位血液的企图。
Bloodloc系统有效地防止了因单位或受血者错误识别导致的潜在输血相关死亡。
