Wrong Blood, Wrong Patient, What now?

Blood360 Bedside is the final key piece in maintaining the integrity of the blood products and the safety of the patient. Scan the patient’s wristband to confirm their identity and then the unit of Blood; Blood360 will then cross check that the identifiers match. This gives the user confidence and stops serious harm or death to a patient in your care. True Positive Patient ID at the Bedside.

Failure of correct patient identification in an emergency

Two patients with the same first name were having identical procedures in theatre. The first patient bled excessively, but the MHP (Mass Hemorrhage Protocol) was activated for the wrong patient. Red cells were sent to the clinical area for the patient who was not subject to an MHP. The blood was returned to the transfusion laboratory issue refrigerator. Blood was then sent to theatres for the correct patient. The incident occurred out-of-hours at the end of the week. The notes of the wrong patient were used for identification.

Page 59, Error Reports: Human Factors, (PHB Bolton-Maggs (Ed) D Poles et al. on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group. The 2015 Annual SHOT Report (2016)

Blood360 stops incidents like this from happening, Blood is requested at the bedside by scanning the patient’s wristband. Before the Transfusion, the patient’s wristband must be scanned using the handheld device to positively identify the patient. If the user scanned the wrong patient they are alerted on the handheld device and the system will not let them proceed with the Transfusion. A message is also sent to the Lab informing them of the mistake.

When the user positively identifies the correct patient, the Blood unit is scanned and the system then checks if it is a match for the patient. Only when these two match and the system has checked if the Blood unit has not expired can they start the Blood Transfusion.

You can also take and record all the observations on the Blood360 handheld, these fully configurable questions included the mandatory taking of 15 minute and/ or 1-hour observations. MEWS is automatically calculated and appropriate steps advised for a deteriorating patient.