There was clearly a pressing need for a uniform blood band at three of the healthcare provider's facilities. Two of the facilities were using a two-step label band that required assembly by the hospital's phlebotomists. Patient safety was compromised because the band accommodated only small, hard-to-read text and lacked a barcode to provide a second security check.
A third facility was using the Ident-A-Blood band system, with labels that were too large for the blood tubes in use and uncomfortable metal closures that created risks of choking and bacterial contamination.
With the original workflow, patients were identified by name and DOB on their armband. During blood specimen collection, a collector applied a blood band to the patient's wrist, prepared the specimen label, and collected the blood sample. With only a matching number on the specimen label and the blood band, there was only one point of patient- to-specimen match, and no way to perform a second identity check.
Then, the collector took the specimen to the lab where a laboratory technologist manually entered the label number into the blood bank computer system. Typing the label number into the system added risk of a transcription error that could negatively affect testing and transfusion.
Next, a nurse gathered and verified patient information after the doctor ordered up a transfusion. Small numbers on the blood band compromised readability, and different bands from each facility created confusion among "floating" nurses who worked flexible shifts.
Upon administering transfused blood to the patient, a nurse had to manually type the blood band number into the EHR system, creating yet another risk of a transcription error.