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