Documentation errors in transfusion chain: Challenges and interventions.

Area of Science:

• Transfusion Medicine
• Clinical Pathology
• Patient Safety

Background:

• Accurate documentation is critical throughout the transfusion chain.
• Documentation errors can occur at multiple stages, impacting patient safety.
• Interventions are needed to manage and reduce transfusion-related errors.

Purpose of the Study:

• To evaluate the frequency of documentation errors during the blood transfusion process.
• To assess the effectiveness of implemented interventions in managing transfusion errors.
• To analyze the impact of bedside procedures on transfusion accuracy.

Main Methods:

• Study conducted at Aga Khan University, Pakistan (2016-2018).
• Identified transcription and bedside documentation errors using computerized systems and medical charts.
• Calculated WBIT (wrong blood in tube) rates and ABO-mismatched red cell transfusion rates.
• Used Chi-square for statistical analysis of error relationships.

Main Results:

• Consistent WBIT rates (0.8 unadjusted, 0.6 cryptic per 1000 samples) observed from 2016-2018.
• 1161 transcription errors (1.1%) noted in 105,064 blood samples.
• ABO-mismatched transfusion rate decreased from 0.9 to 0.4 per 10,000 RBC transfusions post-intervention.
• Compliance with checklist, ABO technique, and interpretation was 88%, 40%, and 24% respectively.

Conclusions:

• Sample labeling errors were not significantly improved by training or counseling.
• Timely and correct bedside ABO-typing and checklist use can effectively control ABO-mismatched transfusions.
• Interventions focusing on procedural compliance are crucial for transfusion safety.