491 / Using computer-based systems to prevent ABO incompatible transfusion reactions

ITALY
Classification of the PSP
Type of Patient Safety Practice Safe
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Blood / Blood products
Communication There is no specified text here
Topic of the reported practice
Clinical guidelines or pathways
Aim and the benefit of the Patient Safety Practice
 
AS a result of the transfusion errors occurred over the last years, we have been developing a project aiming to apply technology to safety of processes, given the fact that analysis of transfusion-related severe accidents showed that 70% of them occurs at the patient bedside
Description of the Patient Safety Practice
 
Since the use of I-Trac raised some problems, it was decided to introduce the biometric system Securblood, through which we wanted to assure traceability of blood and proper association between patient, sample taken and blood bag and guarantee staff presence during phase 1 of transfusion. Using the patient fingerprint is very important to carry out patient identification at the moment of taking the sample and at the moment of transfusion. Furthermore thanks to the physician fingerprint taken after checking the patient blood bag, his/her presence is verified. Patients have not been involved in this phase. Patients and citizen associations will be successively involved. Results: The percentage of recording of transfusion outcomes before using a safety system= 61%, has been increasing in the 7 years of I-trac system implementation up to 95%. Further information available at: http://buonepratiche.agenas.it/practicesdetail.aspx?id=3627
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
There is no specified text here
There is no specified text here
There is no specified text here
Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Unit or ward level
Specific and measurable outcome for the reported practice were defined
Yes
A baseline measurement before implementation of the reported practice was obtained
Yes
A measurement after full implementation of the reported practice was obtained
Yes
Evaluation of a "positive" effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Quantitative
Enclosure of a reference or attachment in case of published evaluation's results
- Pagliaro B., Turdo R., Capuzzo E., Patients'positive identification systems. Blood Transfusions 2009:7:313-8
- Pagliaro B., Cavedaschi T., Turdo R, Evaluation of a new transfusion security system with fingerprint sensor and transfusion result transmission, ISBT Conference 2007
There is no specified text here
Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Yes
Specification of implementation in another health care setting(s)
Hospital
Successful implementation's level  of this Patient Safety Practice across settings
Yes, across multiple specialities within the same setting
Involved health care staff
 
Physicians
Nurses
Technical support / technician
Quality manager
Risk manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
Yes
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
Patient(s)
Point of time in which service user or their reprasentatives' involvement takes place
During the development of the Patient Safety Practices
During implementation of the Patient Safety Practices
During evaluation of the Patient Safety Practices
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
Yes
Short description of the service users' level of involvement
Consultation, such as asking for information
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
Yes
List of sources where public information is accessible
http://buonepratiche.agenas.it/practicesdetail.aspx
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Yes
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
No
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Equipment was enhanced or new
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here
Contact information
 
Name: Enrico Capuzzo; Rosalia Turdo; Massimo Franchini
Country: ITALY
Organisation: A.O. `CARLO POMA` - MANTOVA
E-mail: enrico.capuzzo@aopoma.it
Phone: 0376 201440
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