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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.
Vox Sanguinis
|August 25, 2001
Summary
Transfusion errors are frequently under-reported. Most errors occur outside the blood bank, particularly at the patient
Area of Science:
- Medical Error Analysis
- Patient Safety
- Transfusion Medicine
Background:
- Transfusion errors are often under-reported due to low staff awareness of adverse events.
- Inadequate feedback systems contribute to the under-reporting of transfusion errors in many centers.
Purpose of the Study:
- To investigate the sources and types of transfusion errors within a tertiary care hospital.
- To identify the primary locations where transfusion errors occur.
Main Methods:
- Blood bank staff and patient-responsible residents reported errors over one year.
- Errors were classified based on their site of occurrence within the hospital.
Main Results:
- A total of 123 transfusion errors were detected during the study period.
- The majority of errors, 107 (86.99%), occurred outside the blood bank.
- Only 16 (13%) errors were identified as occurring within the blood bank.
Conclusions:
- Transfusion errors predominantly happen outside the controlled environment of the blood bank.
- The patient's bedside is identified as the most common location for transfusion errors.