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Case Study O2 - Discussion Part 1 - Mistake-Proofing Tools
 

TraQ Program of the BC PBCO

Wednesday, 29 March 2017

Case Study O2 - 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 (Just kidding! 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 ofVancouver 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.T he 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.Anexample 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 theFDA is promotingbar codes and RFID technologyand 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 ofBlood-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 fromLeveraging 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 forerrors 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?

Answer

2. Which group of mistake-proofing examples used in transfusion processes (see above) are designed to prevent communication errors?

Answer

3. Which type of error are patient barcodes and radio frequency identification designed to prevent?

Answer

4. What are some of the limitations of technological mistake-proofing devices?

Answer

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.

Further Reading

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Last modified on Tuesday, 12 April 2011 13:49