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Related Concept Videos

Errors occurring during blood pressure monitoring01:25

Errors occurring during blood pressure monitoring

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Blood pressure monitoring is a crucial clinical procedure in diagnosing and managing various cardiovascular conditions. Despite its significance, the accuracy of blood pressure measurements can be compromised by multiple factors, potentially leading to either falsely high or low readings. These inaccuracies are critical as they can significantly impact patient care. So, it is vital to understand these challenges deeply and adopt strategic approaches to minimize errors.
Several factors...
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Blood Transfusion01:15

Blood Transfusion

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Blood transfusion is a critical medical procedure that saves lives and treats various medical conditions. It involves transferring blood from a donor to a recipient. This process requires a thorough understanding of the ABO blood group system and its associated antigens and antibodies.
Blood Transfusion Overview
A blood transfusion is a medical procedure used to replace blood lost due to injury, surgery, or to treat conditions such as anemia or cancer. During a transfusion, donor blood is...
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Blood Transfusion and Agglutination02:45

Blood Transfusion and Agglutination

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Blood transfusion is a therapeutic measure to restore the blood volume after extensive blood loss due to an accident or a medical procedure. Blood transfusion involves drawing a certain amount of blood from a suitable donor and infusing it into the recipient.
History
The history of blood transfusion dates back to the 17th century, when early attempts were made in animals. In 1818 James Blundell, a British doctor, performed the first successful human blood transfusion. Later in 1900, Karl...
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Systematic Error: Methodological and Sampling Errors01:15

Systematic Error: Methodological and Sampling Errors

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In the case of systematic errors, the sources can be identified, and the errors can be subsequently minimized by addressing these sources. According to the source, systematic errors can be divided into sampling, instrumental, methodological, and personal errors.
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Fundamental Attribution Error01:14

Fundamental Attribution Error

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According to some social psychologists, people tend to overemphasize internal factors as explanations—or attributions—for the behavior of other people. They tend to assume that the behavior of another person is a trait of that person, and to underestimate the power of the situation on the behavior of others. They tend to fail to recognize when the behavior of another is due to situational variables, and thus to the person’s state. This erroneous assumption is...
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Random Error01:04

Random Error

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Random or indeterminate errors originate from various uncontrollable variables, such as variations in environmental conditions, instrument imperfections, or the inherent variability of the phenomena being measured. Usually, these errors cannot be predicted, estimated, or characterized because their direction and magnitude often vary in magnitude and direction even during consecutive measurements. As a result, they are difficult to eliminate. However, the aggregate effect of these errors can be...
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Related Experiment Video

Updated: Feb 3, 2026

Microfluidic Flow Chambers Using Reconstituted Blood to Model Hemostasis and Platelet Transfusion In Vitro
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Microfluidic Flow Chambers Using Reconstituted Blood to Model Hemostasis and Platelet Transfusion In Vitro

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Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative Blood

Nadia B Hensley, Colleen G Koch, Peter J Pronovost

    Joint Commission Journal on Quality and Patient Safety
    |November 4, 2018
    PubMed
    Summary

    Implementing bedside bar code transfusion verification (BBTV) and the Epic anesthesia information management system (AIMS) significantly improved the accuracy of intraoperative blood transfusion documentation and patient safety in the operating room.

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    Area of Science:

    • Medical Safety
    • Health Informatics
    • Quality Improvement

    Background:

    • Intraoperative blood transfusions often rely on manual patient-blood product verification, posing safety risks.
    • Paper-based documentation systems contribute to errors in dual-signature verification processes.
    • A critical incident highlighted the need for enhanced safety protocols in operating room transfusions.

    Purpose of the Study:

    • To improve the safety and documentation accuracy of intraoperative blood component transfusions.
    • To implement and evaluate a bedside bar code transfusion verification (BBTV) system.
    • To integrate BBTV with an anesthesia information management system (AIMS).

    Main Methods:

    • A multidisciplinary team implemented a four-phase bedside bar code transfusion verification (BBTV) system.
    • Manual audits assessed documentation accuracy from July 2014 to June 2016.
    • Automated audits using the Epic anesthesia information management system (AIMS) were conducted post-July 2016.

    Main Results:

    • Compliance with documentation metrics (electronic signatures, transfusion times, volume) exceeded 96% after BBTV and Epic AIMS implementation.
    • Pre-implementation audits showed only 86% compliance, largely due to missing paper requisitions.
    • The integrated system enhanced the reliability of intraoperative transfusion documentation.

    Conclusions:

    • Bedside bar code transfusion verification (BBTV) integrated with the Epic anesthesia information management system (AIMS) enhances intraoperative blood transfusion safety.
    • The novel documentation process within Epic AIMS improved compliance and reduced transfusion errors.
    • This technological integration represents a significant advancement in patient safety during surgical procedures requiring blood transfusions.