Implementation challenges of electronic blood transfusion safety systems: Lessons from an international, multi-site comparative case study

Stijn Horck*, Nick Fahy, Trisha Greenhalgh

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

BACKGROUND: Severe transfusion reactions resulting from errors in matching the correct blood with the correct patient are considered never events. Despite the relative technical simplicity of barcode scanning for patient-blood bag matching, the adoption and universal application of this safety measure are by no means universal. This study highlights the logistical and institutional challenges associated with spreading, scaling up, and sustaining such IT-supported safety measures in healthcare. STUDY DESIGN AND METHODS: We report findings from a 5-year, prospective, multi-site case study conducted across one hospital in England and three hospitals in the Netherlands. Ethnographic methods, including interviews and observations, were used at each site to investigate the implementation of barcode scanning-supported safety pathways for blood transfusions. RESULTS: Significant variation was observed across the sites in the adoption and implementation of barcode scanning-supported safety pathways. Despite the potential for reducing transfusion errors, the introduction of this innovation was met with varying levels of success in different settings. DISCUSSION: This study highlights the critical role of inter-hospital learning and flexible system design in successfully implementing barcode scanning-supported safety pathways for blood transfusions. A more structured, national-level network for knowledge sharing could enhance the spread and sustainability of such innovations across healthcare settings.
Original languageEnglish
Article number13095
Number of pages12
JournalTransfusion Medicine
DOIs
Publication statusE-pub ahead of print - 9 Sept 2024

Keywords

  • bedside-scanning
  • implementation
  • organisational learning

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