Enhancing transfusion safety with an innovative bar-code-based tracking system

In an effort to reduce transfusion errors, a novel, comprehensive, computerized wireless bar-code-based tracking system for matching patients, blood samples and blood products was created and deployed at a major academic medical centre. With a grant from the Agency for Healthcare Research and Quality, software was developed to track scans at the times of sample collection, sample arrival in the blood bank, blood product dispensation from the blood bank and blood product administration. The system was deployed in February 2005. The system was well accepted from the outset, and the sample rejection rate due to clerical errors fell from 1.82 to 0.17%; incident reports fell by 83%. At the final blood administration step, the accumulated data as of November 2008 indicated that identification errors were being detected and prevented every 42.4 days and that the scan completion rate was stable at about 99%. Process analysis suggested that these were independent events and, thus, would be expected to coincide (and potentially produce a mis-transfusion) every 4,240 days (11.6 years) on average. We estimate that the system is 10 times safer than the manual system previously employed at our institution and may be 15-20 times safer than most systems employed in the United States.