Pretransfusional electronic crossmatch prevents transfusion to the wrong patient

Background

At our institution, we recorded one ABO-mismatched transfusion to a wrong patient each in 2020, 2021 and 2022, representing a rate of about 1:25,000 detected transfusions to the wrong patient. As a corrective and preventive measure and to improve patient safety, the Transfusion Responsible Person with support by the Transfusion Committee and the Regional Physicians Association (Landesärztekammer) enforced the introduction of an electronic pretransfusional crossmatch into clinical practice.

Methods

Our bloodbank information system (BIS) was supplemented with a pretransfusion electronic crossmatch module. Instead of a data interface between the BIS and the patient information system (KIS), a direct web-surface based entry from patient case in KIS into the BIS was established using the Windows login and password of the transfusing physician (step i) and allocating the physician to the patient (ii). Next steps are entry of bed side test results and confirmation by Windows password (iii), scan of blood product barcode (iv), and the electronic crossmatch between patient , bed side test, blood group results, issued product and product scanned on site (v). This results in a GO - PROCEED WITH TRANSFUSION or STOP - DO NOT TRANSFUSE! (step vi).

Results

The pretransfusion e-crossmatch module was first tested in one small outpatient unit in June 2022 and then underwent minor adaptations which helped to establish a smooth process. Training about wrongly administered products was given to physicians in an E-learning module. The system started into clinical routine in October 2022. By now, the application is mandatory in 5 clinical units covering ca. 15% of all transfusions at our University Hospital. After about 3000 pretransfusionally e-crossmatched products, the first near miss was recorded. The physician was in the process to transfuse a patient to whom the product was not assigned; the transfusion was prevented through interference by the pretransfusional e-crossmatch module.

Conclusion

Establishment of a pre-transfusional e-crossmatch is feasable in a University Hospital environment. Operational simplicity of the method, reliability of day-to-day function, and understanding of the risk of transfusing a wrong blood product are important for acceptance by personnel. It allows to stop paper documentation and controls for 100% documentation according to Transfusion Law (TFG). The first case of a near-miss transfusion of a product to the wrong patient proved function of the system.

Offenlegung Interessenkonflikt:

keine

Invited talks abstract/summary