Dr. Terry Gernsheimer

Blood Center-SCCA Joint Project Yields Positive Results on Positive ID

Safe is safe, right?

Well, not exactly. If people are involved, it’s possible for mistakes to be made. After all, people are only human.

That’s as true in medicine as in anything else. So the goal of the “Patient Safety Initiative,” is to take an extremely safe process and edge it closer to perfection.

“Whenever you streamline, you make it harder for people to make errors,” says Puget Sound Blood Center’s Terry Gernsheimer, M.D. She cites studies illustrating that people often read what they expect to see. “That’s where most transfusion-related errors are made – in patient identification and sample labeling.” The use of machine-readable technology, such as barcoding, catches the “misread” by humans who are pressured to do their jobs as quickly as possible.

As the Blood Center’s director of Medical Transfusion Services at University of Washington Medical Center, medical director of Transfusion at Seattle Cancer Care Alliance (SCCA), and chair of UW’s Transfusion committee, Dr. Gernsheimer has long advocated the use of technology to make transfusion safer.

Her advocacy eventually led the Blood Center and SCCA to undertake the Patient Safety Initiative to provide a secure, stable and reliable system of positively identifying a patient prior to blood transfusion.

“The goal of the project is to show that information can be successfully exchanged between the SCCA computer systems and the Blood Center computer system’s two-dimensional barcodes to positively identify the patients in each system,” explains Peggy Dunn, the Blood Center’s IT director, and manager of the project.

Team members included Blood Center and SCCA staff, and employees of Neoteric, which donated equipment and software. “A secondary goal is to increase efficiency,” says Dr. Gernsheimer. “And when efficiency is increased, safety is increased.”

(Left) The handheld scanner allows access to patient-specific information contained in the two-dimensional barcode; (Right Steve Dinwiddie demonstrates bar code scanning.

Successful Pilot
To participating staff, the Patient Safety Initiative is also known as the “2D barcode project.” The name refers to the two-dimensional barcode technology employed in the patient ID wristband and blood unit labeling.

Unlike the familiar one-dimensional barcodes on groceries and other retail items that are scanned at checkout lines, 2D can be read in two directions and therefore contains much more data.

This is an important feature for the patient wristband, which is too small to hold all the necessary data in either print or one-dimensional barcode. Under the new system, the 2D information on the wristband would match up with the information stored in Blood Center computers and blood unit labels for positive identification.

The more information there is to be scanned, the better the match. That’s especially true when the matching procedure is repeated at multiple checkpoints at both hospital and Blood Center. The likelihood of human error is reduced appreciably.

“The SCCA staff has handheld devices to scan the wristbands,” explains Steve Dinwiddie, IT administrator for the Blood Center’s Transfusion Service.

Until now, hospitals generally have relied on sight-reading the printed label information (name, hospital ID, gender, etc.) on the blood units and match with the hand-written name on hospital wristbands. “Most hospitals don’t have the scanning technology yet,” says Dinwiddie. The efficiency and added safety of the new 2D system may prompt hospitals to reconsider.

	Peggy Dunn

Tracking Process
According to Dinwiddie, the tracking process is straightforward. SCCA staff uses a device to print a 2D barcode, containing necessary information, for the patient wristband, and then a label with both barcode and “eye-readable” information is generated for the patient’s blood sample.

The sample is sent to the Blood Center, where staff keys (and ultimately will scan) the information into the system. Lab staff then types the blood, fills the physician’s order (e.g., irradiated, leukocytereduced, etc.) and sends the unit – with Blood Center scannable compatibility label – to SCCA, where hospital personnel using handheld devices scan both patient wristband and blood unit.

Patient care staff also prints a label for the patient’s chart and uploads the information to the hospital tracking system database. Once the patient has been positively identified, the transfusion is started.

If the patient has an adverse reaction, it will eventually be possible to enter that information into the database via the handheld scanners. During the full transfusion cycle from SCCA to the Blood Center and back, healthcare staff uses the handheld scanners and 2D barcodes to positively identify the patient at multiple control points in the process.

Good Start
The 90-day pilot program, which involved a limited number of SCCA patients, concluded successfully in August and Dr. Gernsheimer presented the results to the UW’s Medical Quality Improvement Committee on Oct. 3.

“We wanted to truly close the loop on ID,” says Dr. Gernsheimer. “And although SCCA hasn’t had a problem, it’s always possible, and this was a good place to start the project because of the closely monitored patient population and limited number of staff we have there.”

Phase 2 is currently underway with SCCA’s outpatients. Phase 3 will follow next year.

“The SCCA and Blood Center really want to make this happen,” says Dr. Gernsheimer. “Nothing is foolproof, but this is the best system we’ve seen yet.”