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Discussion - Part 1 (Mistake-Proofing Tools)
Communication deficiencies are common causes of adverse events. Patients with special
transfusion needs such as those requiring irradiated or CMV-negative
blood components are particularly at risk when communication fails. The spectrum of
communication deficiencies includes:
- physicians failing to communicate with nurses, technologists,
pharmacists, and other health professionals and vice versa
- attending physicians failing to communicate with
residents and interns
- staff from one unit failing to communicate with
those from others
- staff on one shift failing to communicate with
those on the next shift
- documentation failing to accompany patients from facility to
facility
- health personnel failing to listen carefully to patients
One of many corrective actions for communication
deficiencies includes developing and
implementing mistake-proofing tools.
Before considering communication tools specifically designed for patients with special
transfusion needs such as being on fludarabine therapy, we begin by discussing mistake-proofing tools in general.
MISTAKE-PROOFING
TOOLS Mistake-proofing
is designing processes or devices to help prevent errors or make
them obvious at a glance. Synonyms include error-proofing, fail-safing,
and the politically incorrect dummy-proofing and idiot-proofing.
Mistake-proof devices are common in
daily life. Think of the
- outlet at the top of bathroom sinks and
tubs
- beeping alerts when keys are left in cars or headlights are left
on
- computer dialogue box that asks, "Do you want to save the changes
you made...."
- computer discs that will only go
in the A drive the correct way (go ahead - try it!)
Mistake-proofing is also commonly used in
transfusion processes, and include:
- Checklists for specific processes, e.g.,
- inspection checklist for receiving blood into inventory
- pretransfusion nursing checklist
- competency assessment checklists
- Colour-coding as visual cues, e.g.,
- ABO antisera
- crossmatched versus emergency blood bag tags
- allogeneic versus autologous blood donation tags
- Standard terminology (in-house and universal) to minimize
misunderstanding, e.g.,
- vw = microscopic-only agglutination (in-house definition)
- "poopy" = it's probably neg but I'm paranoid (
in-house definition)
- 4+ = solid button, clear background (universal
definition)
- massive
transfusion
= replacement of patient's total blood volume in < 24 hrs
(universal definition)
- Cross-checking work done by others, e.g.,
- supervisory review of worksheets
- two nurses checking patient and donor unit identification when
blood is transfused
- check digit on blood bag labels used to ensure accuracy of manual data entry
of donor identification numbers
NEWER
MISTAKE-PROOFING DEVICES
Because hemovigilance systems have revealed misidentification errors
as transfusion hot spots, several new mistake-proofing tools are
being promoted to eliminate identification errors1,
2 Three of the newer tools are
discussed below.
1. Barcodes
Use of barcodes on donor bag labels is an old technology in blood
banking. In 2004, the U.S. FDA instituted a rule requiring bar codes on
drugs and blood to help reduce errors.
A newer use is to track identity by
using barcode readers and hand-held computers to read barcodes on
patient wrist bands, blood specimens, crossmatch request forms, and
donor bag compatibility tags.
Several companies provide integrated barcode systems, including
Neoteric Technology Limited of Vancouver Canada, partnered
with Olympus, which offers Blood TrackTM
Courier and Blood TrackTM Safe Tx. Here's a
description kindly provided by a colleague in the UK, whose
transfusion service uses
BloodTrack
CourierTM:
Very briefly, the system controls door locks on our blood
fridges. Only validated staff can access the fridges.
The interface is via a touch screen monitor and bar code
scanner. We went for this option as it utilises graphics and
sounds. When blood is moved, it is scanned in or out of the fridge
and the system checks that the blood has not been out of the
fridge too long (30 mins by hand, 3hrs by cool box - all user
configurable), or that it has not expired or that it is not in the
wrong location. If it is OK, it gets a green light and
audible message, otherwise a red light and a warning message, and
a message is sent back to the lab. With this, we have quite
an effective audit trail.
2. Radio frequency identification
(RFID)
RFIDs, like barcodes, are a form of automatic identification and
data capture. An example of an RFID application is the
anti-theft hard plastic tags attached to clothes in stores (if the
tag has been left on an item, it beeps loudly when customers try to
exit the store). There
are many
more current
RFID uses.
RFID is similar to a wireless barcode in which information
is sent via radio waves (see RFID
technology for details). Unlike barcodes, RFID tags can
withstand harsh conditions and can store and update information as
the tag move through a process, keeping key information with the tag
and making it available at any point in the process. In the USA
the FDA
is promoting bar codes and RFID technology and has cleared a surgical RFID
marker to protect surgical patients.
3. Barrier
systems One mechanical barrier system is
Blood-Loc, a combination-lock-secured disposable
bag3. The combination for the lock is unique and only available to
transfusing staff on the patient’s wrist ID band. Blood-Loc insures that positive identification occurs before the blood can be unlocked and transfused. See
a discussion of
Blood-Loc
and RFID systems on CBBS e-Network Forum.
Limitations of
technology
Technological mistake-proofing is
expensive to implement. Costs relate to hardware, software,
maintenance, servicing, and staff training and competency
assessment. As well, new devices always have technical
limitations. Like clinical trials of new drugs, they require time
and large numbers of users to identify all of the problems.
While mistake-proofing technologies such as barcodes and RFID
can help prevent identification errors, they have limitations.
Excerpt from Leveraging
RFID for hospitals (conference report - no longer online):
In 1998, Georgetown University Hospital
initiated a series of transfusion safety
studies using barcode-enabled point-of-care (BPOC) systems
(wristbands, labels for blood samples, labels for blood containers.
and hand-held scanners. After more than 1,000 BPOC transfusions, we
concluded that
transfusion safety
systems must be combined with similar medication safety
systems to generate the volume of day-to-day transactions necessary
for nurses to maintain proficiency and confidence. We also observed
that bar code scans of patients’ wristbands have a certain number
of failures because of food spills, crinkles, or shower-related
smudges.
The frequency of these incidents varies with the number of
days of hospitalization, patient’s age, and personal habits. To
further study this issue, we initiated our current study using
dualpurpose wristbands that are encoded with both bar-codes and RFID
chips and scanned using a hand-held device that can be switched
easily from bar code to RFID scanning. (Gerald Sandler)
Besides preventing misidentification, technology-driven mistake proofing is also
promoted as a way to reduce communication
deficiencies leading to medication and transfusion errors.4 If all
patient information is maintained in a central computer database and
accessible by all caregivers, fewer mistakes should occur.
Regardless of the utility of technology, effective interaction
between healthcare workers is critical to patient safety.5
Complexity and
errors
Note that complexity increases the
opportunity for errors to occur. Some mistake-proofing tools
make it impossible to make errors and others attempt to reduce the
complexity of performing a process.
If
SOPs are overly complicated, staff may
become confused and make errors. Overly complex SOPs may also stimulate workers to circumvent the SOP using unapproved workarounds
that result in adverse outcomes. When investigating errors and
taking corrective action, we should be careful that the fixes do not
make an operating procedure so complex as to increase the risk of
staff making errors.
TraQ Self
Study Questions
1. What is mistake-proofing and what
are some synonyms?
2. Which group of mistake-proofing
examples used in
transfusion processes (see above) are designed to
prevent communication errors?
3. Which type of error are patient
barcodes and radio frequency identification designed to prevent?
4. What are some of the limitations of
technological mistake-proofing devices?
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MORE
DISCUSSION...
REFERENCES
1.Dzik WH, Corwin H, Goodnough LT, Higgins M, Kaplan H, Murphy M, et al
.Patient safety and blood transfusion: new
solutions. Transfus Med Rev 2003 Jul;17(3):169-80.
2. Turner CL, Casbard
AC, Murphy MF. Barcode
technology: its role in increasing the safety of blood transfusion.
Transfusion. 2003 Sep;43(9):1200-9
3. Wenz B, Burns ER. Improvement
in transfusion safety using a new blood unit and patient
identification system as part of safe transfusion practice.
Transfusion 1991 Jun;31(5):401-3.
4. Bates DW. Using information technology to reduce rates of medication errors in
hospitals. Br Med J 2000;320:788-91.
5. Coffey RP. Technology
cannot replace healthcare workers (letter). Br Med J
2000;321:505.
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