Intraoperative blood mistransfusion is not a term many anesthesia professionals think of when administering blood products in the operating room, but it becomes an acute reality to you, your anesthesia department, and the operating room staff when it happens to your patient. Over the years, hospitals and governing agencies have set forth checks, guidelines, and protocols that have made mistransfusion sound like something from historical literature due to such improvement in patient safety, but mistransfusion still occurs today. According to the European Commission’s annual reporting of serious adverse events and reactions (SARE) reviewing 24,043,766 blood products administered over a year, the rate of a serious adverse event occurs 9.8 times
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There is much research into eliminating human error at all stages of the blood transfusion process, from the point the blood sample is drawn to the time the blood product is administered, by the use of technology. One example of such technology is the use of barcode labels and scanning in the place of, or in conjunction with the patients’ wristband.4 Using this technology, a bedside barcode/label is generated for both the blood sample and the patient wristband. This barcode will be physically attached to the patient and when blood products are to be administered, this barcode will be checked with the hospitals’ blood bank database along with the patients’ barcode as part of the final bedside check before blood product administration. Similar to this concept of eliminating human error are the two-dimensional barcode (increased reliability and usability) and the patient-specific radio frequency identification (RFID) code. The RFID system is unique from the traditional scanners in that it doesn’t require line of sight between the scanner and patient armband and the reading isn’t obscured by water, dirt, or blood. Both of these are more expensive than the standard barcode system, but are slowly gaining popularity.2 It is important to point out that these uses are only to be thought of as adjuncts to a complete bedside check to provide a valuable final failsafe check. Overreliance on these technologies can lead to near misses or, even worse,
There is much research into eliminating human error at all stages of the blood transfusion process, from the point the blood sample is drawn to the time the blood product is administered, by the use of technology. One example of such technology is the use of barcode labels and scanning in the place of, or in conjunction with the patients’ wristband.4 Using this technology, a bedside barcode/label is generated for both the blood sample and the patient wristband. This barcode will be physically attached to the patient and when blood products are to be administered, this barcode will be checked with the hospitals’ blood bank database along with the patients’ barcode as part of the final bedside check before blood product administration. Similar to this concept of eliminating human error are the two-dimensional barcode (increased reliability and usability) and the patient-specific radio frequency identification (RFID) code. The RFID system is unique from the traditional scanners in that it doesn’t require line of sight between the scanner and patient armband and the reading isn’t obscured by water, dirt, or blood. Both of these are more expensive than the standard barcode system, but are slowly gaining popularity.2 It is important to point out that these uses are only to be thought of as adjuncts to a complete bedside check to provide a valuable final failsafe check. Overreliance on these technologies can lead to near misses or, even worse,