Evaluation of alert-based monitoring in a computerised blood transfusion management system

Blood transfusion is a critical and multi-step process that can be lifesaving. At the same time, any mistakes can be life threatening. An electronic blood transfusion system has been designed to ensure the correctness and safety of the blood transfusion process. The standards for the system include notification mechanisms to inform system managers of any errors in the process. Analysis of system alerts has been used to evaluate the performance of the system. The majority of alerts were classified as 'moderate' in terms of risk (i.e. operational rather than affecting clinical safety) and tended to result from user error. The process of alert acknowledgement and resolution by the system administrator acted as a bottleneck whenever the alerts increased above 100 items per month. Although there was no statistically significant correlation between the number of alerts and the number of transfusions or number of the new users of the system, relatively similar patterns were observable in their charts. A major benefit is that the alerts automatically provided information that would not be captured in a manual transfusion process.