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Sources of preventable errors related to transfusion
R R Sharma1, S Kumar, S K Agnihotri
1Department of Transfusion Medicine, Post Graduate Institute of Medical, Education and Research, Chandigarh, India.
Background And Objectives:
Transfusion errors always remain under-reported owing to a lack of awareness about transfusion-related adverse events among the hospital staff and an inadequate feedback system in most of the transfusion centres. This article reports the results obtained from a study carried out to investigate the sources and types of errors in our tertiary care hospital.
Materials And Methods:
The errors reported by the blood bank staff (i.e. reception counter clerical and technical staff) and the residents in charge of the patient, were studied over a period of 1 year (from May 1998 to April 1999) and classified based on the site of occurrence.
Results:
A total of 123 errors were detected over the 1-year study period. Of these 123 errors, 107 (86.99%) occurred outside the blood bank and 16 (13%) in the blood bank.
Conclusion:
Errors occur most frequently outside the blood bank, and the bedside of the patient is the main location.