Emily Cooley Lecture 2002: transfusion safety in the hospital

rimum non nocere (“First, do no harm”) is an ancient reminder that patients should not be subjected to unsafe or harmful medical practices. In recent years, concern over harm to patients has gained renewed attention. Patient injury and death due to errors resulting from unsafe processes in healthcare was highlighted by the 1999 Institute of Medicine’s report “To err is human.” 1 The need to reassert patient safety as a top priority cuts across all branches of healthcare and includes transfusion medicine. This paper summarizes the 2002 Emily Cooley lecture, which called for a realignment of priorities in the field of transfusion medicine away from excess attention to the component and toward the interests of the patient. Transfusion safety is concerned with the overall process of delivering transfusion care to the patient. During the past three decades, resources devoted to the quality of the blood component have resulted in impressive improvements in blood safety. However, overall transfusion safety, largely the province of hospitals, has received far less attention. As a result, serious problems exist at each step of the hospital process of transfusion care. High rates of mislabeled and completely miscollected patient samples have been documented. The physician’s decision to transfuse is hampered by the absence of controlled clinical trials and the absence of formal training in transfusion therapies. The final bedside check required to insure that the unit is intended for the recipient is often performed either incompletely or incorrectly, resulting in millions of unsafe transfusion episodes each year. Mistransfusion of blood remains the single most common serious hazard of transfusion, is the most likely cause of death attributed to transfusion, and occurs at a rate thousands of times higher than transfusion-transmitted HCV and HIV combined. Solutions to current problems in hospital transfusion safety can be grouped into three categories: First, new technology designed to improve patient safety should be explored. Machine-readable patient identification wristP bands, smart pumps, and radio-frequency smart labels may reduce transfusion errors. Nanotechnology holds great promise to improve clinical decision-making regarding transfusion, and computerized blood utilization review (CBUR) can provide timely and useful educational feedback to prescribing physicians. Second, a new position—the transfusion safety officer (TSO)—charged with the responsibility for improving the process of transfusion care outside the laboratory should be developed in the US. TSOs have already been deployed in several nations to identify and resolve latent organizational weakness leading to unsafe transfusion practice. Third, professional societies should become advocates for patient welfare by setting performance standards in key areas of the transfusion process including the collection of patient samples, bedside blood administration, and staffing levels in laboratories directly responsible for blood support of patients. Clinical research is urgently needed to define better the indications for transfusion and to explicitly evaluate proposed new safety interventions. Hospital transfusion safety represents a top priority for the profession of transfusion medicine.