Bedside Transfusion Errors: Analysis of 2 Years' Use of a System to Monitor and Prevent Transfusion Errors
- 1 January 1996
- journal article
- Published by Wiley in Vox Sanguinis
- Vol. 70 (1), 16-20
- https://doi.org/10.1111/j.1423-0410.1996.tb00990.x
Abstract
Clerical errors occurring during specimen collection, issue and transfusion of blood are the most common cause of ABO incompatible transfusions. 40–50% of the transfusion fatalities result from errors in properly identifying the patient or the blood components. The frequency and type of errors observed, despite the implementation of measures to prevent them, suggests that errors are inevitable unless major changes in procedures are adopted. A fail‐safe system, which physically prevents the possibility of error, was adopted in January 1993 and concurrently a quality improvement program was implemented to monitor any transfusion errors. Up to December 1994, 10,995 blood units (5,057 autologous and 5,938 allogeneic) were transfused to 3,231 patients. Seventy‐one methodological errors (1/155 units) were observed, half of which were concentrated during the first 4 months of introducing the system. However the system detected and avoided four potentially fatal errors (1/2,748 units). Two cases involved the interchanging of recipient sample tubes, 1 case was due to patient misidentification and the other involved misidentification of blood units. In conclusion the system is effective in detecting otherwise undiscovered errors in transfusion practice and can prevent potential transfusion‐associated fatalities caused by misidentification of blood units or recipients.Keywords
This publication has 15 references indexed in Scilit:
- Transfusion Errors: Causes and EffectsTransfusion Medicine Reviews, 1994
- Monitoring transfusionist practices: a strategy for improving transfusion safetyTransfusion, 1994
- A report of 104 transfusion errors in New York StateTransfusion, 1992
- Acute normovolemic hemodilutionTransfusion, 1991
- Improvement in transfusion safety using a new blood unit and patient identification system as part of safe transfusion practiceTransfusion, 1991
- It's in the bag! (or is it?)Transfusion, 1991
- Reports of 355 transfusion‐associated deaths: 1976 through 1985Transfusion, 1990
- Intraoperative Blood Salvage: Medical ControversiesTransfusion Medicine Reviews, 1990
- Predeposited Autologous Blood for Elective SurgeryNew England Journal of Medicine, 1987
- Blood Transfusion AccidentsBMJ, 1953