Bar Code-Based ID Systems for Blood Tranfusions
As you’ve learned during your studies for the ABIM certification test, a primary concern during a blood transfusion is an acute hemolytic transfusion reaction. The following post examines one possible solution to preventing such an error.
Bar codes are ubiquitous in our everyday life. Classically, they’ve been found on bananas and other produce at the grocery store. More recently, they’ve cropped up on menus and in magazines, enticing people to scan them with smart phones. And now, according to recent research from Dr. Gregory Nuttali and his colleagues at the Mayo Clinic, they are also found on patients and on bags of blood.
In 2002, the Mayo Clinic initiated a bar code patient identification system, where every patient that entered the hospital had a bar code added to her ID bracelet. Four years later, the Mayo Clinic blood bank used the bar code ID system to label its blood bags with information including the medical record number, blood product unit number, and the blood product type. The thought was that this system would result in a reduction in transfusion errors.
To test this hypothesis, Nuttali et al., using a retrospective chart analysis, compared the rates of mis-identification and near-miss events — vaguely defined as a “narrowly avoided attempt to administer blood to the wrong patient” — before and after the implementation of the bar code ID system.
Their data, published in the April 2013 issue of Mayo Clinic Proceedings, is comprehensive. They analyzed a total of 388,837 units of transfused blood prior to the ID system, and a total of 304,136 units of transfused blood after the institution of the system.
Interestingly, they found that there was no statistically significant reduction in rates of mis-identification after the ID system began. Of note, with the bar code ID system there was only 1 episode where a blood product was transfused to the wrong patient.
However, there was a dramatic increase in the number of near-miss events (34 after the ID system began, compared to 1 before). The authors believe this is because after the ID system was instituted, near-miss events were automatically reported. Prior to that, the reporting of transfusion errors was entirely voluntary.
Blood transfusion science has come a long way since the early 1990s, when hemophiliacs and other at-risk patient populations who regularly required blood transfusions were infected with HIV and hepatitis, due to the shoddy blood processing protocols in place. Thankfully, those days are long past us.
The more recent concern regarding acute hemolytic reactions isn’t purely academic. Between 2005 and 2009, acute hemolytic transfusion reactions were the second most common reported cause of death from blood transfusions in the US.
With the implementation of the bar code ID system at the Mayo Clinic, hopefully the rate of transfusion errors in the future will be reduced to zero. Given the promising findings, perhaps other hospitals in the US will follow suit and also place bar codes on their patient’s ID bracelets.
Indeed, bar codes are no longer only found in grocery stores and magazines.
You can find other posts by Dr.Feng on the Knowmedge Blog. You can find also additional topics and questions directly from the Knowmedge Internal Medicine ABIM Board Exam Review Questions QVault. _____________________________________________________________________
Charles Feng is an allergy / immunology fellow at UC Davis. He has worked as an internal medicine physician at Kaiser Permanente.
