JMIR Publications

ABSTRACT

Background:

A Bar Code Transfusion Management BCTM) system was developed and has been implemented since 2011 in Taipei Veterans General Hospital(TVGH) to improve the efficiency of nursing processes for 60,000 prescriptions of blood transfusion each year.

Objective:

This quality improvement report describes the efforts to develop the BCTM and examines its effectiveness in reducing blood transfusion errors at TVGH.

Methods:

The BCTM system uses barcodes for patient identification, onsite labelling of the filled sample tube on the phlebotomy cart, and blood product verification through a wireless connection to the hospital information systems. Process maps before (2008-2010) and after (2011-2017) the implementation of the BCTM system are shown to highlight the changes. The numbers of incorrect labelling or wrong blood in tube incidents that occurred quarterly were plot on a run chart to monitor the quality changes for each intervention introduced. Plan-Do-Study-Act cycles were used to improve the process. The incident reports of near-miss cases from the Blood Centre were reviewed by researchers to determine cause and type of errors, and the annual occurrences of near-miss events before and after the implementation of the BCTM system were compared with the mean occurrence to determine whether the BCTM system significantly reduced the number of errors. The outcomes of prescriptions for blood transfusion by physicians and the types of adverse events managed during transfusion were recorded in the BCTM database and used to assess the overall quality of transfusion therapy at TVGH.

Results:

The near-miss rate decreased from 0.015% in 2011 to 0.003% in 2016 and 0.001% in 2017, resulting in a significant improvement after implementation of the BTCM system (p<0.05). Only one incorrect labelling incident and no incorrect transfusions occurred among 68,326 transfusion orders in 2017.

Conclusions:

This report demonstrates that continuous efforts to upgrade the existing process, via barcodes and information technology, can reduce errors in transfusion therapy.