Blood product positive patient identification: comparative simulation-based usability test of two commercial products

Transfusion. 2011 Nov;51(11):2311-8. doi: 10.1111/j.1537-2995.2011.03185.x. Epub 2011 May 20.


Background: The blood product administration process has been subject to various quality improvement initiatives aimed at reducing errors, including blood product labels that are missing, inaccessible, unreadable, or mismatched to orders and/or patients. This article reports the results of a formal simulation-based usability test of two comparable technologies designed to reduce blood product administration errors.

Study design and methods: Nineteen nurses and three anesthesia providers evaluated one of the two products during simulated use in realistic scenarios during 90-minute test sessions. Both products required additional learning despite 15 minutes of dedicated vendor-provided pretest training.

Results: There were significant effectiveness differences between the two products, but use of both devices was less efficient than manual checking. Usability issues included poor access to subtasks, lack of process feedback, inadequate error messaging, and confusing device interactions.

Conclusion: While clinicians' subjective ratings of both devices were similarly high, both products had significant usability issues likely to lead to clinician frustration and workarounds during actual use. This study suggests that usability testing is a valuable and more effective method than preference surveys of determining the ability of blood administration products to meet clinicians' needs in the complex world of patient care.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Blood Transfusion*
  • Female
  • Humans
  • Male
  • Medical Errors
  • Middle Aged
  • Patient Identification Systems*
  • Patient Safety
  • Transfusion Reaction
  • User-Computer Interface*