[Protection against mismatched transfusion during operation double check system]

Area of Science:

• Medical Safety
• Transfusion Medicine
• Surgical Patient Care

Context:

• The operating room at Iwamizawa Municipal General Hospital experienced three blood type recording errors within a three-month period (June-August 2004).
• These errors highlighted a critical vulnerability in patient safety protocols regarding blood transfusions.

Purpose:

• To develop and implement a robust blood typing verification system to eliminate transfusion errors.
• To enhance patient safety by preventing mismatched blood transfusions during surgical procedures.

Summary:

• A multi-step verification protocol was introduced, involving distinct blood typing and compatibility testing locations, standardized documentation with red pen notation, confirmation by multiple staff members, and verbal checks before anesthesia and transfusion.
• The system mandates loud verbal confirmation of patient blood type, preserved blood type, and compatibility test numbers by both anesthesiologists and nurses.

Impact:

• Following the implementation of the enhanced system from September 2004 to March 2005, no blood typing errors occurred.
• The study demonstrates that a rigorous double-check system for blood types in surgical patients is effective in preventing mismatched transfusions.