輸血用検体の採血前と血液製剤の輸血前における患者照合に関する多施設 アンケート調査

Several reports have explored the value of electronic identification systems (EISs) in reducing incorrect blood recipient identification. Here, we report a multi-institutional study to clarify the usage and limitation of EISs for pretransfusion sample collection and blood administration. From October 2020 to March 2022, 26 institutions were registered in the study. 15 (58%) used EISs for blood collection, and 25 (96%) for administration. In several institutions, EISs were not implemented in departments in which massive bleeding may occur, such as the emergency department, operating room and angiography room. 12 institutions reported 52 cases of error and near-miss events of wrong blood in tubes and wrong component transfusion. Blood samples were collected from the wrong patient in 17 cases, EISs were not used before blood administration in 8, and the wrong component was transfused to patients in 7. Of 52 errors and near-miss events, EISs were not used properly in 41 (79%). Clinical staff did not understand the use of EISs before blood collection and administration in 9 and forgot electronic patient identification before blood collection or administration in 5, and electronic patient identification was not performed before blood collection or administration due to an emergency situation in 3. Further efforts are needed to improve patient safety in the transfusion process. [ABSTRACT FROM AUTHOR]