Bedside Transfusion Errors: Analysis of 2 Years' Use of a System to Monitor and Prevent Transfusion Errors

Abstract

Clerical errors occurring during specimen collection, issue and transfusion of blood are the most common cause of AB0 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.

Comparing near misses with actual mistransfusion events: a more accurate reflection of transfusion errors

“…Guidelines should therefore be simple, convenient and portable. About half (10 out of 21) of the near misses related to ABO mismatch, with the potential for signi®cant morbidity and sometimes mortality if errors were not detected early (Mercuriali et al, 1996). The frequency and seriousness of failing to check patients' details at the bedside before transfusion was highlighted, as we found over half (4 out of 7) of mistransfusions occurred here.…”

“…It is, therefore, timely that as the drive for`zero risk' option in transfusion-transmitted diseases continues we should now look more closely at the other arm of the transfusion safety process, the blood supply chain, to minimize procedure-related errors in transfusion. National guidelines already exist (BCSH, 1990;BCSH, 1996), aimed at ensuring safety at the various stages of blood supply process, but compliance is far from complete in most reports (Mercuriali et al, 1996;Lumadue et al, 1997;Williamson et al, 1999b). Concern about the prevalence and importance of transfusion-related errors has led to the UK Departments of Health recommending a number of management actions (NHS Executive Letter, 1999) to minimize the complications of blood transfusion A near miss is any error that, if undetected, could result in wrong blood group determination or in the issue of an incorrect or inappropriate component, but which was recognized before transfusion occurred (Williamson et al, 1999a).…”

Managing the Pre- and Post-analytical Phases of the Total Testing Process

“…Identification errors can result in inappropriate treatment and mislabeling of blood specimens may result in hemolytic transfusion reactions from incompatible blood [44, 45]. Up to 50% of transfusion-related deaths result from identification error [46-49]. Up to 1 in 18 identification errors can result in an adverse patient outcome [50].…”

Efficacy of Preoperative Autologous Blood Donation

“…The system is effective in detecting and preventing potentially fatal errors and complies with the usual protocol for allogeneic and AB transfusion. 26 Another issue to consider is the expense of PABD. Blood harvested by PABD is generally considered more costly than allogeneic blood.…”