Ordering blood for the wrong patient--getting inside the minds of ordering physicians.

摘要: Objective To assess the impact on ordering errors when physicians stopped handwriting patient identifiers requests for blood transfusion. Material and Methods Physicians, frustrated by amount of time required to complete paper forms order blood, asked if requirement handwritten identifiers, which were in addition such information "stamped" requests, could be eliminated. We acquiesced request, modified accordingly, continued monitor errors. Results After elimination 1997, increased from an annual rate 1 10,000 6 late 1999. alerted clinicians newsletter, decreased somewhat (3 requests). However, error did not decrease its previous level until mid-2001, about 21/2 years after reinstitution identifiers. Conclusion An obligatory second entry demographic a requires carefully consider identity receiving transfusion reduces likelihood unintended recipient. Error management tools, as predetermined method planning, reviewing, documenting all changes, facilitate detection trends responses corrective actions.