Improvement in transfusion safety using a specially designed transfusion wristband

Sample collection and sample handling errors submitted to the transfusion error surveillance system, 2006 to 2015

BACKGROUND

In Canada, transfusion-related errors are voluntarily reported to a tracking system with the goal to systematically improve transfusion safety. This report provides an analysis of sample collection (SC) and sample handling (SH) errors from this national error-tracking system.

STUDY DESIGN AND METHODS

Errors from 2006 to 2015 from 23 participating sites were extracted. A survey was conducted to obtain information regarding institutional policies. Samples received in the blood bank were used to calculate rates. "Wrong blood in tube" (WBIT) errors are blood taken from wrong patient and labeled with intended patient's information, or blood taken from intended patient but labeled with another patient's information.

RESULTS

A total of 42,363 SC and 14,666 SH errors were reported. Predefined low-severity (low potential for harm) and high-severity errors (potential for fatal outcomes) increased from 2006 to 2015 (low SC, SH: 13-27, 3-12 per 1000; high SC, SH: 1.9-3.7, 0.5-2.0 per 1000). The WBIT rate decreased from 12 to 5.8 per 10,000 between 2006 and 2015 (p < 0.0001). The overall WBIT rate was 6.2 per 10,000, with variability by site (median, 0.3 per 10,000; range, 0-17 per 10,000). Sites with error detection mechanisms, such as regrouping second sample requirements, had lower error rates than sites that did not (SC, SH: 12, 1 per 1000 samples vs. 17, 3 per 1000 samples; p < 0.0001).

CONCLUSION

WBIT rates decreased significantly. Low-severity error rates are climbing likely due to increased ascertainment and reporting. Prevention studies are necessary to inform changes to blood transfusion standards to eliminate these errors.

Administration Safety of Blood Products - Lessons Learned from a National Registry for Transfusion and Hemotherapy Practice

BACKGROUND

Compared to blood component safety, the administration of blood may not be as safe as intended. The German Interdisciplinary Task Force for Clinical Hemotherapy (IAKH) specialized registry for administration errors of blood products was chosen for a detailed analysis of reports.

METHODS

Voluntarily submitted critical incident reports (n = 138) from 2009 to 2013 were analyzed.

RESULTS

Incidents occurred in the operation room (34.1%), in the ICU (25.2%), and in the peripheral ward (18.5%). Procedural steps with errors were administration to the patient (27.2%), indication and blood order (17.1%), patient identification (17.1%), and blood sample withdrawal and tube labeling (18.0%). Bedside testing (BST) of blood groups avoided errors in only 2.6%. Associated factors were routine work conditions (66%), communication error (36%), emergency case (26%), night or weekend team (39%), untrained personnel (19%). Recommendations addressed process and quality (n = 479) as well as structure quality (n = 314). In 189 instances, an IT solution would have helped to avoid the error.

CONCLUSIONS

The administration process is prone to errors at the patient assessment for the need to transfuse and the application of blood products to patients. BST is only detecting a minority of handling errors. According to the expert recommendations for practice improvement, the potential to improve transfusion safety by a technical solution is considerable.

Report on errors in pretransfusion testing from a tertiary care center: A step toward transfusion safety

INTRODUCTION

Errors in the process of pretransfusion testing for blood transfusion can occur at any stage from collection of the sample to administration of the blood component. The present study was conducted to analyze the errors that threaten patients' transfusion safety and actual harm/serious adverse events that occurred to the patients due to these errors.

MATERIALS AND METHODS

The prospective study was conducted in the Department Of Transfusion Medicine, Shri Maharaja Gulab Singh Hospital, Government Medical College, Jammu, India from January 2014 to December 2014 for a period of 1 year. Errors were defined as any deviation from established policies and standard operating procedures. A near-miss event was defined as those errors, which did not reach the patient. Location and time of occurrence of the events/errors were also noted.

RESULTS

A total of 32,672 requisitions for the transfusion of blood and blood components were received for typing and cross-matching. Out of these, 26,683 products were issued to the various clinical departments. A total of 2,229 errors were detected over a period of 1 year. Near-miss events constituted 53% of the errors and actual harmful events due to errors occurred in 0.26% of the patients. Sample labeling errors were 2.4%, inappropriate request for blood components 2%, and information on requisition forms not matching with that on the sample 1.5% of all the requisitions received were the most frequent errors in clinical services. In transfusion services, the most common event was accepting sample in error with the frequency of 0.5% of all requisitions. ABO incompatible hemolytic reactions were the most frequent harmful event with the frequency of 2.2/10,000 transfusions.

CONCLUSION

Sample labeling, inappropriate request, and sample received in error were the most frequent high-risk errors.

Blood sample collection and patient identification demand improvement: a questionnaire study of preanalytical practices in hospital wards and laboratories

Scand J Caring Sci; 2010; 24; 581-591 
 Blood sample collection and patient identification demand improvement: a questionnaire study of preanalytical practices in hospital wards and laboratories

BACKGROUND

  Most errors in venous blood testing result from human mistakes occurring before the sample reach the laboratory.

AIMS

  To survey venous blood sampling (VBS) practices in hospital wards and to compare practices with hospital laboratories.

METHODS

  Staff in two hospitals (all wards) and two hospital laboratories (314 respondents, response rate 94%), completed a questionnaire addressing issues relevant to the collection of venous blood samples for clinical chemistry testing.

RESULTS

  The findings suggest that instructions for patient identification and the collection of venous blood samples were not always followed. For example, 79% of the respondents reported the undesirable practice (UDP) of not always using wristbands for patient identification. Similarly, 87% of the respondents noted the UDP of removing venous stasis after the sampling is finished. Compared with the ward staff, a significantly higher proportion of the laboratory staff reported desirable practices regarding the collection of venous blood samples. Neither education nor the existence of established sampling routines was clearly associated with VBS practices among the ward staff.

CONCLUSIONS

  The results of this study, the first of its kind, suggest that a clinically important risk of error is associated with VBS in the surveyed wards. Most important is the risk of misidentification of patients. Quality improvement of blood sample collection is clearly needed, particularly in hospital wards.

Errors reported in cross match laboratory: a prospective data analysis

BACKGROUND

Human errors contribute to one half of all ABO-incompatible transfusions and transfusion-associated fatalities.

MATERIAL AND METHODS

We report distribution, type and frequency of errors through a prospective study designed specifically to determine errors reported in the cross match lab with their clinical outcome, and to investigate the contributing factors, and underlying system problems.

RESULTS

A total of 342 errors (6.2 per 1000 samples) were reported with majority of the errors being clerical (87.1%) and occurred outside the blood bank (86.5%). Labelling errors were the most frequent incidents encountered with bedside being the major site of deviation. The rate of labeling errors was 6.4 errors per 1000 samples (0.64%) in 32,189 samples studied. Among 80,100 components transfused, the frequency of incorrect blood component transfusion (IBCT) was estimated to be 22.5/100,000 blood components transfused. Miscollected samples (WBIT) occurred at a rate of 1 in 1532 samples (0.65 per 1000 samples). More than half of these errors occurred during the day shift (9 errors per 1000 request form) but more with urgent demands (11 errors per 1000 request form).

CONCLUSION

This study indicates the importance of proper specimen labeling and implemented cost-effective, non-compromising policy of rejecting each mislabelled specimen and realises the importance of ongoing quality monitoring to improve laboratory performance.

Blood still kills: six strategies to further reduce allogeneic blood transfusion-related mortality

After reviewing the relative frequency of the causes of allogeneic blood transfusion-related mortality in the United States today, we present 6 possible strategies for further reducing such transfusion-related mortality. These are (1) avoidance of unnecessary transfusions through the use of evidence-based transfusion guidelines, to reduce potentially fatal (infectious as well as noninfectious) transfusion complications; (2) reduction in the risk of transfusion-related acute lung injury in recipients of platelet transfusions through the use of single-donor platelets collected from male donors, or female donors without a history of pregnancy or who have been shown not to have white blood cell (WBC) antibodies; (3) prevention of hemolytic transfusion reactions through the augmentation of patient identification procedures by the addition of information technologies, as well as through the prevention of additional red blood cell alloantibody formation in patients who are likely to need multiple transfusions in the future; (4) avoidance of pooled blood products (such as pooled whole blood-derived platelets) to reduce the risk of transmission of emerging transfusion-transmitted infections (TTIs) and the residual risk from known TTIs (especially transfusion-associated sepsis [TAS]); (5) WBC reduction of cellular blood components administered in cardiac surgery to prevent the poorly understood increased mortality seen in cardiac surgery patients in association with the receipt of non-WBC-reduced (compared with WBC-reduced) transfusion; and (6) pathogen reduction of platelet and plasma components to prevent the transfusion transmission of most emerging, potentially fatal TTIs and the residual risk of known TTIs (especially TAS).

Safety and reliability of Radio Frequency Identification Devices in Magnetic Resonance Imaging and Computed Tomography

BACKGROUND

Radio Frequency Identification (RFID) devices are becoming more and more essential for patient safety in hospitals. The purpose of this study was to determine patient safety, data reliability and signal loss wearing on skin RFID devices during magnetic resonance imaging (MRI) and computed tomography (CT) scanning.

METHODS

Sixty RFID tags of the type I-Code SLI, 13.56 MHz, ISO 18000-3.1 were tested: Thirty type 1, an RFID tag with a 76 x 45 mm aluminum-etched antenna and 30 type 2, a tag with a 31 x 14 mm copper-etched antenna. The signal loss, material movement and heat tests were performed in a 1.5 T and a 3 T MR system. For data integrity, the tags were tested additionally during CT scanning. Standardized function tests were performed with all transponders before and after all imaging studies.

RESULTS

There was no memory loss or data alteration in the RFID tags after MRI and CT scanning. Concerning heating (a maximum of 3.6 degrees C) and device movement (below 1 N/kg) no relevant influence was found. Concerning signal loss (artifacts 2 - 4 mm), interpretability of MR images was impaired when superficial structures such as skin, subcutaneous tissues or tendons were assessed.

CONCLUSIONS

Patients wearing RFID wristbands are safe in 1.5 T and 3 T MR scanners using normal operation mode for RF-field. The findings are specific to the RFID tags that underwent testing.

Strict adherence to a blood bank specimen labeling policy by all clinical laboratories significantly reduces the incidence of "wrong blood in tube"

Phlebotomy errors leading to incompatible transfusions are a leading cause of transfusion-related morbidity and mortality. Our institution's specimen-labeling policy requires the collection date, 2 unique patient identifiers, and the ability to identify the phlebotomist. This policy, however, was initially strictly enforced only by the blood bank. In fiscal year 2005, following an educational campaign on proper specimen labeling, all clinical laboratories began strictly adhering to the specimen-labeling policy. Compared with the preceding 4 years, in the 3 years following policy implementation, the incidence of wrong blood in tube (WBIT) and mislabeled specimens detected by the blood bank decreased by 73.5% (0.034% to 0.009%; P < or = .0001) and by 84.6% (0.026% to 0.004%; P < or = .0001), respectively. During a short period, a simple, low-cost educational initiative and policy change can lead to statistically significant decreases in WBIT and mislabeled specimens received by the blood bank.

Patient‐centred care – preanalytical factors demand attention: A questionnaire study of venous blood sampling and specimen handling

OBJECTIVE

Most mistakes in laboratory medicine are the result of human error occurring before the blood sample reaches the laboratory. This survey of preanalytical procedures was designed to identify sources of error and potential targets for quality improvement strategies.

MATERIAL AND METHODS

The staff in a highly specialized surgical ward at a university hospital completed a questionnaire addressing the collection and handling of venous blood samples in plastic vacuum test-tubes for general clinical chemistry testing.

RESULTS

The results suggest that venous blood sampling instructions are not always followed. When uncertain about how a sample should be collected, the majority of respondents rely on potentially poor sources of information, such as out-of-date printed instructions or the advice of a colleague, rather than consult up-to-date electronic instructions. Furthermore, they do not always report errors and the referrals are not always handled according to sampling instructions. The respondents were highly motivated, however, and had a strong interest in receiving further education in, and assuming increased responsibility for, venous blood sampling procedures in the ward.

CONCLUSIONS

We believe that the introduction of standardized routines and regular staff training, combined with an exchange of the existing paper-based referral management system with an electronic system for managing referrals, could increase safety in the preanalytical process, with positive effects on patient safety. Given the importance of venous blood samples in patient care, a more extensive study covering other hospital wards and primary health-care centres is needed.

Noninfectious serious hazards of transfusion

As infectious complications from blood transfusion have decreased because of improved donor questionnaires and sophisticated infectious disease blood screening, noninfectious serious hazards of transfusion (NISHOTs) have emerged as the most common complications of transfusion. The category of NISHOTs is very broad, including everything from well-described and categorized transfusion reactions (hemolytic, febrile, septic, and allergic/urticarial/anaphylactic) to lesser known complications. These include mistransfusion, transfusion-related acute lung injury, transfusion-associated circulatory overload, posttransfusion purpura, transfusion-associated graft versus host disease, microchimerism, transfusion-related immunomodulation, alloimmunization, metabolic derangements, coagulopathic complications of massive transfusion, complications from red cell storage lesions, complications from over or undertransfusion, and iron overload. In recent years, NISHOTs have attracted more attention than ever before, both in the lay press and in the scientific community. As the list of potential complications from blood transfusion grows, investigators have focused on the morbidity and mortality of liberal versus restrictive red blood cell transfusion, as well as the potential dangers of transfusing "older" versus "younger" blood. In this article, we review NISHOTs, focusing on the most recent concerns and literature.

Tubes for pretransfusion testing should be collected by blood bank staff and hand labelled until the implementation of new technology for improved sample labelling. Results of a prospective study

BACKGROUND AND OBJECTIVES

The greatest risk in transfusion medicine is actually human error, resulting in the use of the incorrect blood component. The aim of our study was to identify and evaluate the risk factors involved in the collection and labelling of pretransfusion blood samples.

MATERIAL AND METHODS

We prospectively evaluated 6446 samples submitted to the blood bank for pretransfusion testing. Inappropriate samples were classified as 'mislabelled' or 'miscollected'. After 4 months of study, an educational approach was taken.

RESULTS

The frequency of inappropriately labelled samples was 6.45%. Such samples were associated with the use of addressograph labels (vs. hand-written labels) [23.4% vs. 1.4%, P < 0.0001], collection by clinical staff (vs. blood bank staff) [8.8% vs. 2.1%, P = 0.001] and emergency situations (vs. routine sampling) [10.1% vs. 6.1%, P = 0.005]. Following educational intervention, the percentage of inappropriately labelled samples decreased from 7.3% (pre-educational) to 5.8% (post-educational), P = 0.005.

CONCLUSION

Ongoing monitoring and analysis of labelling and collection should be mandatory in order to improve the safety of transfusion.

Error management of emergency transfusions: A surveillance system to detect safety risks in day to day practice

Acute hemolysis due to AB0-incompatibility caused by transfusion of red blood cell concentrates (RBCC) to the wrong recipient is one of the major causes of transfusion-related death. As part of our policy to improve quality and safety in emergency transfusion, we have developed a standardized surveillance system for supplying RBCC in emergency situations. This surveillance system involves the implementation of a standardized set of basic data transmitted from the requesting unit to the blood bank by phone and a scoring system to check for compliance with guidelines and errors in daily routines. Communication deficiencies and delayed pretransfusion sampling were the most common errors.

Nearly two decades using the check-type to prevent ABO incompatible transfusions: one institution's experience

To detect miscollected (wrong blood in tube [WBIT]) samples, our institution requires a second independently drawn sample (check-type [CT]) on previously untyped, non-group O patients who are likely to require transfusion. During the 17-year period addressed by this report, 94 WBIT errors were detected: 57% by comparison with a historic blood type, 7% by the CT, and 35% by other means. The CT averted 5 potential ABO-incompatible transfusions. Our corrected WBIT error rate is 1 in 3,713 for verified samples tested between 2000 and 2003, the period for which actual number of CTs performed was available. The estimated rate of WBIT for the 17-year period is 1 in 2,262 samples. ABO-incompatible transfusions due to WBIT-type errors are avoided by comparison of current blood type results with a historic type, and the CT is an effective way to create a historic type.

Medication safety and transfusion errors in the ICU and beyond

The modern day intensive care unit (ICU) is a place in which patients can receive continuous monitoring of physiologic variables with concentrated patient observation and care. Despite the "intensive care," errors do occur. This article reviews medication and transfusion errors, including the different types, causes, and possible solutions to prevent these errors from occurring in ICUs and the hospital at large.

Experience with the medical event reporting system for transfusion medicine (MERS-TM) at three hospitals

BACKGROUND

The MERS-TM assists hospital transfusion services to identify, analyze, and correct system events relating to the delivery of blood to patients.

METHODS

The MERS-TM system was used from February of 1999 to December 2002. All reported near-miss and actual events were recorded and analyzed.

RESULTS

During these 47 months, 4670 events were reported by the transfusion service. Of these events, 94% were classified as a near-miss event and 93% were detected before the blood product was administered. No ABO-incompatible transfusions were detected despite transfusion of 50,137 units of red blood cells. High severity events with the potential for patient harm accounted for 241 (5%) of the 4670 events. Nursing related events accounted for 188 (78%) of the high severity events. In one out of 4430 (0.023%) samples tested, a high severity sample-testing event was detected. In one out of 1550 (0.06%) samples collected, a high severity sample-collection event was detected.

CONCLUSION

An event reporting system is essential if one is to determine where and how often events are occurring within the transfusion process.

'Tag and label' system for checking and recording of blood transfusions

Guidelines for checking and recording of blood transfusion mandate the use of a blood transfusion compatibility form. We have introduced and assessed a 'tag and label' system that does away with the compatibility form. A compatibility tag with a peel-off self-adhesive label is attached to the unit for transfusion. No compatibility form is issued to the site of the transfusion. The peel-off label is signed and fixed in patient notes at the time of transfusion. We have found the system easier to use and to be preferred by nursing staff administering transfusions. During 2 years, we have transfused over 100,000 blood components, including 70,000 units of red cells, and have not recognized any episode during which the wrong blood was transfused to a patient. Recording in the patient notes of units transfused has significantly improved compared with local and national figures in a previous survey. We conclude that it is possible to dispense with the compatibility form without compromising the safety of the transfusion process.

[Diversity of bedside pretransfusion ABO compatibility devices in metropolitan France]

To prevent the occurrence of the ABO incidental incompatibility, the bedside pretransfusion ABO control is mandatory in France since 37 years. If the quality of the reagents is regularly controlled, no technical specification exists concerning the type of support. To describe the different types of devices used by the French hospitals, a brief questionnaire was sent, from December 2000 to March 2001, to each hemovigilance correspondent working in the 1782 hospitals with transfusion activity in 1999. Every participant had to send back the device used in his establishment. The rate of replies was 29.4%, varying from a region to another. The devices distributed by laboratories were the most used (67.4%) vs. 25.6% for the devices provided by the regional establishments of the French Establishment of Blood and 6.7% for the devices manufactured by hospitals. The presence in the region of a local office of the French Establishment of Blood providing some devices was the only factor determining the choice of the device type (p < 10(-8)). Almost half of the hospitals (46.8%) declared to have renewed their devices after 1996, most often in favor of a device provided by a laboratory (p < 10(-8)). We evaluated 30 different devices taking into account the general presentation, the available information on the device. The results of this survey showed a large disparity and heterogeneity in the quality of the devices used by the French hospitals in the context of a lack of standardization.

Reliability of bedside ABO testing before transfusion

BACKGROUND

Previous studies of bedside transfusion compatibility tests have shown high rates of erroneous transfusion decision, due to defective techniques and poor user performance. An experimental study was conducted to evaluate the error rate obtained with a new ready-to-use device (Vu-Test, Medigis), in comparison with the most popular bedside card used in France (Safety-Test ABO, Diagast Laboratories).

STUDY DESIGN AND METHODS

A stratified random sample of nurses performed, in the clinical departments where they worked, cross-matches on 12 randomly and blindly selected paired donor-recipient blood samples with Safety-Test ABO and Vu-Test. The nurses detected agglutination, interpreted compatibility, decided whether to transfuse, and gave their opinion of the two devices. Three independent experts reviewed photographs of each test result.

RESULTS

Thirty-five trained nurses and 10 student nurses carried out 268 tests with each device. One-hundred ninety tests (70.9%) performed with Safety-Test ABO and 177 tests (66.0%) performed with Vu-Test were entirely error-free (p=0.23). The risk of erroneous detection of agglutination was not different between the devices (p=0.69), but was significantly lower when the nurse had experience in transfusion (p < 0.001). According to the experts, Vu-Test was significantly better than Safety-Test ABO.

CONCLUSION

Although the experts considered Vu-Test to be better than Safety-Test ABO, error rates were high with both devices.

To err is human nature. Can transfusion errors due to human factors ever be eliminated?

BACKGROUND

Fatal hemolytic transfusion reaction due to ABO incompatibility occurs mainly as a result of clerical errors. Blood sample drawn from the wrong patient and labeled as another patient's specimen will not be detected by the blood bank unless there is a previous ABO grouping result.

METHODS

In Hong Kong, we had designed a transfusion wristband system--portable barcode scanner system to detect such clerical errors. The system was well accepted by the house staff and had prevented two BO mismatched transfusion. Other current system of patient's identification may have similar results, but the wristband system has the advantages of being simple, inexpensive and easy to implement. The Hong Kong Government is planning to replace the personal identity card for all citizens with an electronic smart card by 2003. If the new card contains the person's detailed red cell phenotypes in digital code, then the phenotypes of all blood donors and admitted patients will be readily available. It is feasible to issue phenotype-matched blood to patients without any need of pre-transfusion testing, therefore eliminating mismatched transfusions for most patients.

RESULTS

Our pilot study of 474 patients showed that the system was safe and up to 98% of admitted patients could be transfused without delays.

CONCLUSIONS

Patients with rare phenotypes, visitors or illegal immigrants may still need pre-transfusion antibody screen, but if most patients can be issued blood units without testings, the potential savings in health care amount to US$14 million/year.

Pretransfusion compatibility testing for red blood cell administration

The purpose of pretransfusion compatibility testing is to prevent incompatible red blood cell transfusions that could lead to immune mediated hemolytic transfusion reactions. Some hemolytic transfusion reactions may have serious sequelae including hemoglobinemia, disseminated intravascular coagulation, renal failure, and death. This article reviews the most comprehensive recent analyses of the laboratory methods used during pretransfusion compatibility testing in the United States. Most of the laboratory practice data have been published in the College of American Pathologists Transfusion Medicine Survey Sets and in a national survey called the Pre-Transfusion Testing Survey. This article couples and trends the data of these comprehensive surveys with an assessment of the literature to present the current practice of pretransfusion compatibility testing.

Reporting of near-miss events for transfusion medicine: improving transfusion safety

BACKGROUND

Half of the reported serious adverse events from transfusion are a consequence of medical error. A no-fault medical-event reporting system for transfusion medicine (MERS-TM) was developed to capture and analyze both near-miss and actual transfusion-related errors.

STUDY DESIGN AND METHODS

A prospective audit of transfusion-related errors was performed to determine the ability of MERS-TM to identify the frequency and patterns of errors.

RESULTS

Events and near-miss events (total, 819) were recorded for a period of 19 months (median, 51/month). No serious adverse patient outcome occurred, despite these events, with the transfusion of 17,465 units of RBCs. Sixty-one events (7.4%) were potentially life-threatening or could have led to permanent injury (severity Level 1). Of most concern were 3 samples collected from the wrong patient, 13 mislabeled samples, and 22 requests for blood for the wrong patient. Near-miss events were five times more frequent than actual transfusion errors, and 68 percent of errors were detected before blood was issued. Sixty-one percent of events originated from patient areas, 35 percent from the blood bank, and 4 percent from the blood supplier or other hospitals. Repeat collection was required for 1 of every 94 samples, and 1 in 346 requests for blood components was incorrect. Education of nurses and alterations to blood bank forms were not by themselves effective in reducing severe errors. An artifactual 50-percent reduction in the number of errors reported was noted during a 6-month period when two chief members of the event-reporting team were on temporary leave.

CONCLUSION

The MERS-TM allowed the recognition and analysis of errors, determination of patterns of errors, and monitoring for changes in frequency after corrective action was implemented. Although no permanent injury resulted from the 819 events, innovative mechanisms must be designed to prevent these errors, instead of relying on faulty informal checks to capture errors after they occur.

Reducing the frequency of errors in medicine using information technology

BACKGROUND

Increasing data suggest that error in medicine is frequent and results in substantial harm. The recent Institute of Medicine report (LT Kohn, JM Corrigan, MS Donaldson, eds: To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999) described the magnitude of the problem, and the public interest in this issue, which was already large, has grown.

GOAL

The goal of this white paper is to describe how the frequency and consequences of errors in medical care can be reduced (although in some instances they are potentiated) by the use of information technology in the provision of care, and to make general and specific recommendations regarding error reduction through the use of information technology.

RESULTS

General recommendations are to implement clinical decision support judiciously; to consider consequent actions when designing systems; to test existing systems to ensure they actually catch errors that injure patients; to promote adoption of standards for data and systems; to develop systems that communicate with each other; to use systems in new ways; to measure and prevent adverse consequences; to make existing quality structures meaningful; and to improve regulation and remove disincentives for vendors to provide clinical decision support. Specific recommendations are to implement provider order entry systems, especially computerized prescribing; to implement bar-coding for medications, blood, devices, and patients; and to utilize modern electronic systems to communicate key pieces of asynchronous data such as markedly abnormal laboratory values.

CONCLUSIONS

Appropriate increases in the use of information technology in health care- especially the introduction of clinical decision support and better linkages in and among systems, resulting in process simplification-could result in substantial improvement in patient safety.