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C O M M E N T A R Y

Blood transfusion administration—one- or two-person checks:which is the safest method?

Douglas Watson, Joanne Murdock, Carolyn Doree, Michael Murphy, Maria Roberts, Andrea Blest,

and Susan Brunskill

Successive reports from the UK Serious Hazards ofTransfusion (SHOT) scheme have highlightedthat failure of the final patient identificationcheck at the bedside was the most frequent, and

potentially most catastrophic, transfusion error.1 In 2005 ateam of UK transfusion practitioners with the UnitedKingdom Blood Transfusion Services (UKBTS) SystematicReview Initiative undertook a systematic review of thisissue. The current British Committee for Standards inHaematology (BCSH) guidelines for “The administrationof blood and blood components and the management oftransfused patients,” Section 5, “Identity check of patientand unit of blood” states “The bedside check is a vital stepin preventing transfusion error . . . . This procedure hastraditionally involved two members of staff, with at leastone being a qualified nurse or doctor. However, this is acontroversial area, and it has been argued that oneresponsible member of staff would more reliably carry outthe procedure than two (Linden and Kaplan, 1994). Twomembers of staff may rely upon the other to be more rig-orous, resulting in neither giving the task their full atten-tion. It is recommended that one member of staff should

be responsible for carrying out the identity check of thepatient and the unit of blood at the patient’s bedside. Themember of staff must be a doctor or nurse holding currentregistration of the UKCC professional register . . . .”2

The BCSH guidelines were introduced in 1999.2 Sincethen, however, very few hospitals in the United Kingdomhave introduced a policy of one-person checking ofpatient identification for blood transfusion administra-tion. One of 16 hospital trusts (unpublished survey ofTransfusion Practitioners in Scotland, 2006) and 67 of 370hospitals (in a survey cited in the UK SHOT report, 2001/02)3 had introduced one-person checking in some form,either throughout the hospital or in some clinical areas.The reason for failing to implement the recommendationfor one-person checking in the BCSH guidelines isunclear. It may contradict policy for patient identificationin other areas of patient care such as drug administration.It is possible that its implementation requires such a bigchange in policy, practice, and “mindset” that there is areluctance to make this change. It could be due to a per-ceived lack of evidence to support this practice or a fear ofgreater transfusion errors. The SHOT report 2000/2001reported data on a total of 307 “wrong blood transfused”incidents at the bedside check not preceded by earliererrors in the transfusion process. A total of 238 incidentsinvolved two-person checking and 23 involved one-person checking of patient identification (unpublisheddata). It is unclear whether one or two people wereinvolved in the remaining incidents. The lack of denomi-nator data for 2000/2001 on the proportion of transfusionschecked by one person and by two persons means that it isnot possible to estimate the rate of error associated witheach. Furthermore, similar data subsequent to 2000/2001on the breakdown of “wrong blood transfused” incidentsat the bedside check into those associated with one-person and two-person checking are not available fromSHOT (H. Jones, SHOT office, personal communication,May 2007).

The purpose of this systematic review was to establishthe evidence base for current practice recommendationson the safety of one-person in comparison to two-person

ABBREVIATION: BCSH = British Committee for Standards in

Haematology.

From the Effective Use of Blood Group, Scottish National Blood

Transfusion Service, Glasgow; the Northern Ireland Blood Trans-

fusion Service, Belfast; the Systematic Reviews Initiative,

National Blood Service, Oxford Radcliffe Hospital NHS Trust,

and Blood Transfusion Medicine, University of Oxford, Oxford;

the Welsh Blood Service, Cardiff; and the National Blood

Service, Birmingham, UK.

Address reprint requests to: Douglas Watson, Trials

Co-ordinator, Effective Use of Blood Group, Scottish National

Blood Transfusion Service, 25 Shelley Road, Gartnavel, Glasgow

G12 0XB, UK; e-mail: Douglas.Watson@snbts.csa.scot.nhs.uk.

Received for publication August 14, 2007; revision received

October 5, 2007, and accepted October 5, 2007.

doi: 10.1111/j.1537-2995.2007.01605.x

TRANSFUSION 2008;48:783-789.

Volume 48, April 2008 TRANSFUSION 783

checking of patient identity at point of blood administra-tion. The authors are unaware of any other systematicreviews addressing this question.

MATERIALS AND METHODS

A systematic review of the literature has two principalfeatures: clear documentation of the comprehensive strat-egies used to identify sources of evidence and a criticalappraisal of methodologic issues.

The following sources were searched to identifyarticles relevant to this review: MEDLINE (1996-2006);Embase (1980-2006); Cinahl database (1982-2006); theCochrane Library (issue 2006/04); and the RCT databaseof the Systematic Review Initiative established fromsearches of hematology and blood transfusion journals(Transfusion, Transfusion Medicine, Vox Sanguinis, BritishJournal of Haematology) and conference abstracts (Ameri-can Society of Haematology, British Society of Haematol-ogy, British Blood Transfusion Society, InternationalSociety of Blood Transfusion, American Association ofBlood Banks), 1980-2006.

In addition, national and international guidelines andtransfusion Web sites were searched to identify relevantarticles. A full list of Web sites searched is available inSupplementary Table S1.

Search strategySubject-specific free text and index terms were combinedto search the electronic databases and guideline Web sites(see Supplementary Table S2). No study-specific searchfilters were included in the search strategies because,given the believed paucity of evidence for this topic area,we wanted to identify all relevant articles. All searchingwas undertaken in September 2005 and updated inDecember 2006.

Eligibility criteriaArticles which addressed patient identification practice atthe point of blood administration were eligible for inclu-sion. Articles on the use of new technology for patientidentification were included if they presented informationon manual bedside checking.

Articles on error reporting, transfusion safety, andhemovigilance were included if they reported data onchecking and patient identification procedures at thepoint of blood administration. Articles addressing hemo-vigilance or error reporting that did not report details onthe nature of these checking errors were not eligible forinclusion. All eligible articles had to specifically state thenumber of persons involved in the patient identificationprocess.

Selection for inclusionOne reviewer screened all titles and abstracts of articlesidentified by the search strategy for relevance to thereview question. Clearly irrelevant articles were excludedat this stage. The remaining articles were assessed on thebasis of their full text content for eligibility with the crite-ria above, by two reviewers working independently. Theabstracts of potentially eligible foreign-language articleswere translated to enable assessment of eligibility to beundertaken.

Data extractionData were extracted onto a review-specific template. Thedetails extracted were the article characteristics (year andplace of publication and objective of the article), studypopulation, details of the intervention, financial support,type of study design (e.g., guideline or expert opinion),and recommendations for practice.

Where a recommendation for practice was made, theevidence supporting that recommendation was extractedverbatim. Information as to the origin of this evidence,availability of additional supporting data, and changesmade since any previous recommendations were alsorecorded.

Analysis of dataQuantitative analysis of data was intended, where appro-priate, but no trials were identified to support this analy-sis. Instead a qualitative description of the extracted datais reported in the text and tabulated in Tables 1 and 2.

The data were analyzed according to recommenda-tion for practice. Articles where recommendations forpractice were reported were presented separately fromthose where no recommendations for practice werereported but an expert opinion was provided. Where rec-ommendations for practice were made, any evidence thatwas given to support the recommendation has beenreported in this review.

Methodologic quality assessment of the guidelinearticles was undertaken with criteria developed to assessguidelines.4 Details of the components of the method-ologic quality assessment and results are provided inTable 2 and results section, respectively.

RESULTS

A total of 1261 articles were identified from the initialsearch strategy undertaken in September 2005. Initialscreening reduced the number of potentially eligiblearticles to 111. In addition, two eligible guidelines wereidentified from a comprehensive search of guideline Websites.

WATSON ET AL.

784 TRANSFUSION Volume 48, April 2008

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ONE- OR TWO-PERSON PATIENT IDENTITY CHECKING

Volume 48, April 2008 TRANSFUSION 785

A second eligibility screen identified 32 potentiallyrelevant articles. Thereafter, detailed full text screeningreduced the number of eligible articles to 7. Of the 25articles excluded during full text screening, 13 articleswere excluded because they did not specifically report thenumber of persons who were involved in the patient iden-tification process and an additional 12 articles discussednew technology, but did not discuss manual checkinginvolving one or two people.

An updated search was undertaken in December 2006in which an additional 222 potentially relevant articleswere identified. Initial screening reduced the number ofpotentially eligible articles to 22. Full text screening iden-tified no further articles eligible for this review.

Included articlesSeven articles were identified that were eligible for inclu-sion. No randomized controlled trials assessing the safetyof one- versus two-person checking of patient identity atpoint of administration were identified. Because no ran-domized controlled trials were identified to address thisquestion, we chose to include any relevant article thatdiscussed one- versus two-person checking, includingexpert opinion articles.

Of the seven articles identified, three articles werestudies of error reporting,5-7 one was an overview of bloodtransfusion practice,8 one was an overview of hemovigi-lance,9 and two were guidelines.2,10 Full details of the char-acteristics of included studies are presented in Table 1.Articles have been grouped into those that gave specificrecommendations for practice5,7 and those that wereexpert opinion only.6,8,9

Methodologic quality of included articlesMethodologic quality assessment was undertaken for thetwo guidelines articles only, because, of those articlesincluded in this review, guidelines are the only types ofarticles for which methodologic quality assessment crite-ria have been developed. The focus of this assessmentwas the expertise of the authors behind the recommen-dations, the source of the evidence for each recommen-dation, and the quality of the evidence used to developthe recommendations (often referred to as “levels of evi-dence”).4 Details of the findings of this assessment are inTable 2.

In summary, the methodologic quality of the includedguidelines was poor. Both guidelines described the exper-tise of professionals making the recommendations.Neither guideline, however, cited references to othersources of evidence from which the recommendationshave been derived nor graded the quality of the evidenceon which their recommendations were made.

Articles producing recommendationsTwo articles recommended two-person checking ofpatient identity at the point of blood administration.5,7

Article characteristics are reported in Table 1.The article by Linden and coworkers5 provided an

overview of transfusion errors reported in New York Stateover a 22-month period from January 1990 to October1991. Sixty-four of the 104 reported errors were related topatient misidentification at the point of administration.Although no error was reported to be as a direct result ofthe number of persons involved in patient identificationat the point of blood administration, the report recom-mended that two trained members of staff should verifypatient identity before blood administration.

Sharma and colleagues,7 in a study of errors reportedin a large Indian hospital between May 1998 and April1999, assessed 123 errors in 50,000 units of red blood cells(RBCs) issued. Like Linden and colleagues,5 although noerrors were reported to be as a direct result of the numberof persons involved in patient identification at the point ofblood administration, the report also recommended twopeople should check the patient’s identity before bloodadministration.

Articles giving expert opinionThree articles reported an expert opinion but the authorsdid not make any firm recommendations for practice.Linden and Kaplan,6 although previously recommendingtwo-person checking,5 question the two-person checkcommenting that where two people check neither is trulyresponsible. They argued that “not only does the passivecheck have significant potential for distraction, multipleresponsibility itself does not necessarily enhance humanperformance. Unless carefully configured to prevent it, ina system in which two people are responsible for the sametask, neither person is truly responsible” (p. 175). Thisarticle has been cited in another source recommendingone person checking: the 1999 BCSH guidelines.2

Todd,9 an experienced transfusion physician andformer member of the SHOT Committee, in an overview ofhemovigilance, also supported one-person checking forthe reason that the second checker could be passive anddistracted by the pressure of other work. Moreover, Toddcommented that the need for two-person checking mayfurther stress staff on busy and/or understaffed unitsleading to corners being cut and an increase in the risk oferrors being made. One-person checking would free upstaff time and would be likely to reduce errors providedbasic competence is demonstrated.

In contrast, Atterbury,8 a hematology nurse andmember of the BCSH task force/guideline committee atthat time, believed that the involvement of a secondperson in the patient identification process might bebetter as “two pairs of eyes might be better than one”

WATSON ET AL.

786 TRANSFUSION Volume 48, April 2008

(p. 49), particularly where longer and more complex iden-tification numbers are involved. She also argued that asecond alert and informed checker might be a usefulsafety measure.

GuidelinesA search of international guidelines databases (seeSupplementary Table S1) produced two guidelines thatwere eligible for inclusion: the British Committee forStandards in Haematology, 1999 (BCSH)2 and Australianand New Zealand Society of Blood Transfusion, 2004(ANZBT).10 For full details of the origin of the guidelinesand recommendations made, see Table 2.

These two guidelines report conflicting recommen-dations. The BCSH guidelines specifically recommendone-person checking of patient identity at point of admin-istration. The ANZBT10 guidelines recommended twopeople being responsible for checking the patient’s iden-tity, although they did add the comment that there was“also a trend for one person to be responsible for this(checking) action.” As noted above, neither guidelinereported the source of information or grading of evidence.The ANZBT 200410 guidelines, however, do make referenceto, and acknowledge, the BCSH 19992 guidelines, eventhough the recommendation for practice cited in theANZBT 200410 guidelines differs from the recommenda-tion given in the BCSH 19992 guidelines.

DISCUSSION

The objective of this systematic review was to establishthe evidence base for current practice recommendationson the safety of one person in comparison to two peoplechecking patient identity at point of blood administra-tion. No randomized controlled trials were identified toaddress this objective. Seven articles were eligible forinclusion: three expert opinion articles, two articles pro-viding specific recommendations, and two guidelines.

The findings of this systematic review indicate thatthe evidence base for current practice is virtually nonex-istent. Despite a clear recommendation from the BCSHguidelines,2 anecdotal evidence suggests that veryfew hospitals in the United Kingdom have introduceda system of single-person checking of bloodadministration.

A number of other sources of information were iden-tified alongside the eligible articles. None of the additionalsources, however, met the eligibility criteria of this review.Several guidelines recommended the need for checkingpatient identity before blood administration but did notspecify the number of people required.11-13 Increasingly,articles suggest that a second checker could be replacedby the use of technology,14-18 and new technology is

increasingly being used to support the process of patientidentification.

Recommendations appear to be less varied in trans-fusion practice audits. An audit in the United States19

found that 98 percent of institutions (approx. 200) sur-veyed had a policy of two-nurse checking. In many states,two-person checking is a legal requirement. As noted, datafrom the UK SHOT scheme suggest that the greaternumber of bedside patient identification errors occurwith two-person in comparison to one-person checking(H. Jones, personal communication, 2006).

The lack of clarity in this area is exemplified in anAustralian randomized crossover study of medicationadministration,20 cited in Linden and Kaplan.6 The studyreports a small, statistically significant, benefit to requir-ing a second nurse to verify medication administration.The benefit was so small, however, so as to be deemed“clinically unimportant” by the authors. In fact, theauthors recommended the introduction of a system ofone-nurse checking based on the clinical significance ofthe study and the implications for nursing resource.

The benefits of one person checking arguably include1) enhanced patient safety, because one person would bemore rigorous in positively identifying the patient; 2) areduction in the significant amount of clinical staff timecurrently needed to allow a second checker; and 3) areduction in the time taken for the transfusion process,ensuring that blood would not be left out of atemperature-controlled environment for any longer thanis necessary.

In terms of two-person checking, clearly the effective-ness of the second checker is crucial. Toft and Mascie-Taylor21 (p. 211) discuss the concept of “involuntaryautomaticity” and argue that verbal double checking pro-tocols do not always provide the level of safety envisaged,because “involuntary automaticity causes the healthcareprofessionals who have carried out the checks not to rec-ognize that an error is present in the system and thus theyform a false hypothesis regarding the patients’ safety.” Thelevel of training required for a second checker is also anissue.22 If a second checker is involved, he or she needs tocheck patient details independently of the first checker. Arobust checking system is a prerequisite in many otherareas of our health care systems, such as medicationadministration20 and in vitro fertilization checks,23 not justtransfusion practice.

Finally, the issue of patient identification in generalis currently being explored by the National Patient SafetyAgency, and the 1999 BCSH guidelines on the adminis-tration of blood and blood components and the manage-ment of patients receiving transfusions are beingreviewed. One of the NPSA recommendations was toensure that “the compatibility form (or equivalent) andpatient notes are not used as part of the finalcheck . . . .”24 It is hoped this will contribute to a reduc-

ONE- OR TWO-PERSON PATIENT IDENTITY CHECKING

Volume 48, April 2008 TRANSFUSION 787

tion in the unacceptably high incidence of bedsidechecking errors.1,22

Implication for practiceThe findings of this review have no current implicationsfor practice. Current practice is variable within the UnitedKingdom, with the majority of hospitals continuing to usea system of two-person checking. A national survey toassess the current extent of implementation of BCSHguidelines could be used to understand the reasons for thenonimplementation of these guidelines. The results wouldguide clinicians and policy makers in the issues that mayprohibit any future change. There is a need for clarity inany guideline recommendations, and the recommenda-tions themselves need to be backed by robust evidence.This is clearly not the current situation, as this review hasdemonstrated. In sites that have introduced one-personchecking, this practice should be evaluated for its effec-tiveness and safety, and evidence produced to support itscontinued use (or not, as the case may be).

Implication for further researchFollowing this systematic review, and given the differingrecommendations for one-person compared to two-person checking and the lack of evidence to support eitherrecommendation, a randomized clinical trial that evalu-ates the safety and resource requirements of one-personversus two-person checking of patient identity at thepoint of blood administration should be developed andundertaken.

Researchers will have to bear in mind that in the areaof patient identity checking, a number of technology-based systems have been developed with the specific aimof increasing safety. There are a number of clinical studiesthat have been or are in the process of being undertaken toevaluate these systems. Although the use of these tech-nologies should have an important role in patient identitychecking, however, not all hospitals or health care systemswill be able to afford to introduce them. The need for arobust manual patient identity checking system, sup-ported by evidence, is still present.

SUPPLEMENTARY MATERIAL

The following supplementary material is available for thisarticle:Table S1. Guidelines and transfusion Web sites searched.Table S2. Search strategy.This material is available as part of the online article from:http://www.blackwell-synergy.com/doi/abs/10.1111/j.1537-2995.2007.01605.x

ACKNOWLEDGMENTS

We thank Sally Ballard, Sandra Gray, Chris Hyde, Brian McClel-

land, and Simon Stanworth for their comments on the review.

Douglas Watson acknowledges support from fellow authors and

from the Effective Use of Blood Group, SNBTS.

REFERENCES

1. Stainsby D, Jones H, Asher D, Atterbury C, Boncinelli A,

Brant L, Chapman CE, Davison K, Gerrard R, Gray A,

Knowles S, Love EM, Milkins C, McClelland BL, Norfolk

DR, Soldan K, Taylor C, Revill J, Williamson LM, Cohen H;

SHOT Steering Group. Serious hazards of transfusion: a

decade of hemovigilance in the UK. Transfus Med Rev

2006;20:273-82.

2. Murphy MF, Atterbury CL, Chapman JF, Lumley JS,

McClelland DB, Stockley R, Thomas D, Wilkinson J, Bruce

M, Duguid J, Kelsey P, Knowles SM, Murphy MF, William-

son LM; British Committee for Standards in Haematology.

The administration of blood and blood components and

the management of transfused patients. Transfus Med

1999;9:227-38.

3. Serious hazards of transfusion annual report 2001/2002.

Manchester: Serious Hazards of Transfusion Scheme;

2002.

4. Grilli R, Magrini N, Penna A, Mura G, Liberati A. Practice

guidelines developed by specialty societies: the need for

critical appraisal. Lancet 2000;355:103-6.

5. Linden JV, Paul B, Dressler KP. A report of 104 transfusion

errors in New York State. Transfusion 1992;32:601-6.

6. Linden JV, Kaplan HS. Transfusion errors: causes and

effects. Transfus Med Rev 1994;8:169-83.

7. Sharma RR, Kumar S, Agnihotri SK. Sources of prevent-

able errors related to transfusion. Vox Sang 2001;81:

37-41.

8. Atterbury CR, Wilkinson JR. Blood transfusion. Nurs Stand

2000;14:47-54.

9. Todd A. Haemovigilance—closing the loop. Vox Sang

2002;83 Suppl 1:13-16.

10. Australian and New Zealand Society of Blood Transfusion

Inc and Royal College of Nursing Australia. Guidelines for

the administration of blood components. Sydney: Austra-

lian and New Zealand Society of Blood Transfusion Inc and

Royal College of Nursing Australia; 2004.

11. The Association of Anaesthetists. Blood transfusion and

the anaesthetist: red cell transfusion. London: The Associa-

tion of Anaesthetists of Great Britain and Ireland; 2001

[cited 2006 Dec 03]. Available from: http://www.aagbi.org

12. Royal College of Nursing. Guidance for improving transfu-

sion practice: right blood, right patient, right time.

London: Royal College of Nursing; 2004 [cited 2006 Dec

03]. Available from: http://www.rcn.org.uk

13. Finnish Medical Association. Blood Transfusion: indica-

tions and administration. EBM guidelines. Helsinki:

Duodenum Medical Publications Ltd; 2006 [cited 2006 Dec

03]. Available from: http://www.ahcpr.gov

14. Shulman IA, Saxena S, Ramer L. Assessing blood adminis-

tering practices. Arch Pathol Lab Med 1999;123:595-8.

WATSON ET AL.

788 TRANSFUSION Volume 48, April 2008

15. Lau FY, Wong R, Chui CH, Ng E, Cheng G. Improvement in

transfusion safety using a specially designed transfusion

wristband. Transfus Med 2000;10:121-4.

16. Marconi M, Langeberg AF, Sirchia G, Sandler SG. Improv-

ing transfusion safety by electronic identification of

patients, blood samples, and blood units. Immunohema-

tology 2000;16:82-5.

17. Turner CL, Casbard AC, Murphy MF. Barcode technology:

its role in increasing the safety of blood transfusion. Trans-

fusion 2003;43:1200-9.

18. Chan JC, Chu RW, Young BW, Chan F, Chow CC, Pang WC,

Chan C, Yeung SH, Chow PK, Lau J, Leung PM. Use of an

electronic barcode system for patient identification during

blood transfusion: 3-year experience in a regional hospital.

Hong Kong Med J 2004;10:166-71.

19. Novis DA, Miller KA, Howanitz PJ, Renner SW, Walsh

MK;College of American Pathologists. Audit of transfusion

procedures in 660 hospitals. A College of American

Pathologists Q-Probes study of patient identification and

vital sign monitoring frequencies in 16,494 transfusions.

Arch Pathol Lab Med 2003;127:541-8.

20. Kruse H, Johnson A, O’Connell D, Clarke T. Administering

non-restricted medications in hospital: the implications

and cost of using two nurses. Aust Clin Rev 1992;12:77-83.

21. Toft B, Mascie-Taylor H. Involuntary automaticity: a work-

system induced risk to safe health care. Health Serv

Manage Res 2005;18:211-16.

22. Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion

errors in New York State: an analysis of 10 years’ experi-

ence. Transfusion 2000;40:1207-13.

23. Brison DR, Hooper M, Critchlow JD, Hunter HR, Arneson

R, Lloyd A, Horne G. Reducing risk in the IVF laboratory:

implementation of a double witnessing system. Clin Risk

2004;10:176-80.

24. National Patient Safety Agency. Right patient, right blood.

Safer practice notice 14 (9/11/2006). NPSA/2006/14 [cited

2007 July 16]. Available from: http://www.npsa.nhs.uk/

health/display?contentID=5298

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