Transfusion errors in New York State: an analysis of 10 years' experience

Area of Science:

• Medical Safety
• Hematology
• Patient Transfusion Practices

Background:

• Public health concerns often prioritize infectious disease transmission via blood supply.
• Transfusion errors represent a significant, yet often overlooked, cause of adverse patient outcomes.

Purpose of the Study:

• To characterize the types and frequencies of transfusion errors.
• To identify the origins and contributing factors of transfusion errors within a state-wide system.

Main Methods:

• Analysis of mandatory transfusion error reports from 1990-1998 in New York State.
• Inclusion of incidents involving administration to the wrong patient or incorrect ABO/Rh group issuance.

Main Results:

• An error rate of 1 in 19,000 red blood cell (RBC) units administered.
• Half of all errors occurred outside the blood bank, including wrong recipient administration (38%) and phlebotomy errors (13%).
• Blood bank errors accounted for 29% of events, with 15% involving multiple error types, often related to bedside detection failures.

Conclusions:

• Transfusion errors remain a substantial patient safety risk.
• The majority of errors are human-related and potentially preventable.
• Preventing transfusion errors likely requires comprehensive, hospital-wide initiatives beyond the blood bank.