A new Transfusion Safety System (TSS), based on PROCESSES and TECHNOLOGIES, especially, identification by radio frequency (RFID), is currently implemented in two hospitals, a general one (H1) and an Oncology Center (H2). The knowledge of these new near misses will allow designing new transfusion safety indicators.

1. A. Millán¹, A. Mingo¹, MI. González1
, A. Mena2
, JP. Benítez2
¹Banc de Sang i Teixits. BArcelona
²AT-Biotech, Madrid, Spain
A New RFID Transfusion Safety System
BACKGROUND
A new Transfusion Safety System (TSS), based on PROCESSES and TECHNOLOGIES, especially, identification by
radio frequency (RFID), is currently implemented in two hospitals, a general one (H1) and an Oncology Center (H2).
The TSS is fully effective in protecting against incidents, and specifically offers mechanisms to detect Near Misses
(NM).
The TSS allows to analyze the transfusional activity information in real time to project organizational changes in both
transfusion services and hospital units, and to create a new classification of Near Misses.
METHODS
Retrospective analysis of 2016 transfusion activity in both H1 and H2 shows 7970 Pretransfusion sample
collection (PSC) and 12572 Blood component administration (BCA). Retrospective analysis and classification of
6700 safety events occurred during 2016 shows 3579 near misses (2562 in H1 and 1017 in H2).
RESULTS:
CONCLUSIONS:
• The analysis of the transfusion activity information in real time allows implementing
organizational changes, adjusting the work load using the timing and location information
registered.
• TSS allows defining new near misses related to the correct transfusion prescription, the correct
matching of the patient transfusion order with the patient pretransfusion sample and correct
assignment of the blood component to the patient in the Transfusion Service.
• The knowledge of these new near misses will allow designing new transfusion safety
indicators.
AABB Annual Meeting 2017
San Diego CP269
Table 1. Near misses detection
1.- Using Procedural and Physical Barriers
2.- Assuring that the Pretransfusion sample collection (PSC) and the Blood
component administration (BCA) take place at bed side:
a) Location control
b) Interaction with the clinical and transfusion information systems (TIS)
Fig 1. Physical barrier
Table 2. Transfusion Activity Results (2016)
H1. General Hospital H2. Oncology Center
Activity
PSC 6291 (median: 17,24/day) 1679 (median: 4,6/day)
BCA 9217 (median: 25,25/day) 3355 (median: 9,19/day)
Location
BCA Oncology/Hematology 14,07% Brachytherapy 1%
Emergency room 24,11% Palliative cures 4%
Hospitalization 31,65% Day hospital 23%
Intensive Care 5,33% Oncology 10%
Surgery unit 24,85% Emergency room 32%
Hematology 30%
Shifts
BCA 8-15h 39% 8-15h 20%
15-22 43% 15-22 66%
22-08h 17% 22-08h 14%
PSE: Pretransfusion sample collection. BCA: Blood component administration
Table 3. Near misses
H1. General Hospital H2: Oncology Center
Type % Most frequent Type % Most frequent
PSC
42%
(n= 1086)
52,03%: Mistake in
the concordance
between the patient
identification and
the transfusion
request
PSC 47%
(n= 483)
65,84%: error in the
concordance between
the transfusion safety
number in the bracelet
and in the
pretransfusion sample
BCAS 12%
(n= 310)
74,52%: the patient
information in the
TIS does not match
the one registered in
the TSS
BCAS 25%
(n=249)
69,08%: the patient
information in the TIS
does not match the one
registered in the TSS
BCA 46%
(n=1166)
36%: the TSS
detects a not
assigned bracelet
BCA 28%
(n=285)
65,61%: the blood
component is assigned
to another patient
PSE: Pretransfusion sample collection. BCAS: Blood component assignment in the transfusion service.
BCA: Blood component administration.