Ordering blood for the wrong patient--getting inside the minds of ordering physicians

Area of Science:

• Medical Safety
• Healthcare Administration
• Transfusion Medicine

Background:

• Physicians requested elimination of handwritten patient identifiers on blood transfusion request forms due to time constraints.
• The existing process included both stamped and handwritten patient identifiers.

Purpose of the Study:

• To evaluate the effect of removing handwritten patient identifiers on blood transfusion ordering errors.
• To determine if a simplified ordering process impacts patient safety.

Main Methods:

• The requirement for handwritten patient identifiers on blood transfusion request forms was removed.
• Blood ordering error rates were monitored before and after the change.
• Clinicians were alerted to increased errors, and the identifier requirement was later reinstituted.

Main Results:

• Following the elimination of handwritten identifiers, blood transfusion ordering errors increased from 1 in 10,000 to 6 in 10,000 requests.
• After clinician notification, the error rate decreased but remained elevated.
• Reinstating handwritten identifiers led to a sustained reduction in errors to the baseline rate over 2.5 years.

Conclusions:

• A mandatory second entry of patient demographic identifiers on blood orders is crucial for reducing transfusion errors.
• This process ensures physicians verify patient identity, minimizing the risk of transfusing the wrong patient.
• Effective error management strategies, including systematic review and documentation of changes, are vital for identifying and addressing safety trends.