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Human error: the persisting risk of blood transfusion: a report of five cases
Jens Krombach1, Sandra Kampe, Birgit S Gathof
1Department of Anesthesiology, University of Cologne, Germany. krombach@netcologne.de
Unlabelled:
It is common experience that virus transmission, particularly transmission of the human immunodeficiency virus (HIV), is a principal concern of patients and physicians regarding blood transfusion (1). Many physicians are probably unaware that transfusion-transmitted HIV infection is approximately 50 to 100 times less likely to occur than transfusion error (2-4). This misconception may have been encouraged by the scarcity of reports on transfusion error relative to the tremendous public attention focused on HIV infection. We present five cases illustrating how anesthesiologists, intensivists, and emergency physicians are particularly vulnerable to the risk of administering blood to the wrong recipient. All five cases were collected during a 4-yr period. Transfused units of packed red cells totaled approximately 50,000 U during this period in our department.
Implications:
Human error leading to the transfusion of blood to an unintended recipient is a major source of transfusion-related fatalities. We report five cases that highlight some specific areas in which transfusion error is likely to occur.
Insights
Transfusion errors, such as giving blood to the wrong patient, are more common than human immunodeficiency virus (HIV) transmission. This study highlights risks for anesthesiologists and other critical care physicians.
Area of Science:
- Medical safety
- Transfusion medicine
- Patient harm
Background:
- Physicians and patients often fear human immunodeficiency virus (HIV) transmission via blood transfusion.
- This fear overshadows the greater risk of transfusion errors, like administering blood to the wrong recipient.
Observation:
- Five cases of incorrect blood transfusions were documented over a four-year period.
- Anesthesiologists, intensivists, and emergency physicians were identified as particularly vulnerable.
- Approximately 50,000 units of packed red cells were transfused during this time.
Findings:
- Transfusion errors pose a significant risk of patient harm and fatalities.
- Human error is a leading cause of transfusion-related deaths.
Implications:
- Addressing human error in transfusion practices is critical for patient safety.
- Specific interventions are needed to mitigate risks in critical care settings.