In November 2006, the National Patient Safety Agency (NPSA), in partnership with the Chief Medical Officer's National Blood Transfusion Committee (NBTC) and Serious Hazards of Transfusion (SHOT) issued the 'Right Patient, Right Blood' safer practice notice, with recommendations to the NHS to improve the safety of blood transfusions, including the IT specification which is being piloted in this project.

Research by SHOT between 1996 and 2004 showed that five patients died as a direct result of being given incompatible blood. 'ABO' incompatibility also contributed to the deaths of a further nine patients and caused major illness in 54 patients.

Dr Kevin Cleary, Medical Director, National Patient Safety Agency (NPSA), said: "It is imperative that safe systems are in place to ensure that patients are not put at risk by a procedure which is carried out on a daily basis!

"This is a practical and effective solution to support the NHS in providing safer care for patients across the UK who have blood transfusions."

Mayday Healthcare NHS Trust pilot

NHS Connecting for Health (NHS CFH) and the National Patient Safety Agency (NPSA) worked together with Mayday Healthcare NHS Trust, on a blood tracking pilot scheme.

"The National Patient Safety Agency (NPSA) welcomes this report on the pilot of the ECTMS which was developed as part of the NPSA Safer Practice Notice: Right patient right blood. The lessons learnt will be useful for all NHS organisations implementing systems to improve the safety of blood transfusion."- Joan Russell Head of Patient Safety, National Patient Safety Agency

The new system incorporates modern technology to allow blood to be tracked from blood sampling to transfusion, thus helping to ensure that the correct blood is administered to all patients.

Every year, around one million blood transfusions are carried out safely and correctly, but occasionally things do go wrong.

Administering the wrong blood type - also known as 'ABO incompatibility' - is the most serious outcome of blood type error during transfusions. Most of these incidents are due to the failure of final identity checks carried out between patients and the blood to be transfused.

In the pilot, all blood bags are to be tracked using active radio frequency identification (RFID) technology. Patient wristbands will also have passive radio frequency identification RFID chips and are read electronically by staff using hand-held readers, to check each patient's identification and to ensure that patients get the right blood.

Dr Maureen Baker, Clinical Director for Patient Safety, NHS Connecting for Health, said: "Managing the risk factors involved in the area of blood transfusion is a critical area of patient safety and care.

"The introduction of new technologies into the NHS has the potential to significantly minimise patient risk, while NHS staff will benefit from a streamlined, automated process, enabling them to spend more time caring for their patients."

Professor Michael Thick, Chief Clinical Officer, NHS Connecting for Health, said: "We chose Mayday to pilot the Electronic Clinical Transfusion Management System as they met all the criteria and had the best plan for piloting it.

"I am delighted that we are able to make use of these technologies to provide a solution for better, safer care in blood transfusion. Working together with the trust to pilot this project is a real step forward towards safer patient care."

Read the full report by Croydon Health Services Right Patient Right Blood Pilot