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[Analyses of 6 misidentifications in blood sampling in our hospital]

Chiaki Yamada1, Harumi Fujiwara, Naoko Ogawa

  • 1Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan. chiaki@hama-med.ac.jp

Rinsho Byori. the Japanese Journal of Clinical Pathology
|March 17, 2011
PubMed

The initial step of blood transfusion therapy is blood type grouping. ABO-mismatch blood transfusion results in serious adverse effects. 6 incidents in the process of blood type identification, which were caused by misidentification in blood sampling, have experienced in our hospital since October, 2006 to September 2009. We retrospectively examined these incidents, and discussed the reasons and countermeasures. All of 6 incidents were caused by busy residents or nurses during busy hours such as early in the morning or in the emergency. To prevent these incidents, staffs of transfusion unit announced what we have to take care in sampling blood and tied alert tags to sampling tubes. Moreover, we have recently introduced crosschecking computer systems between patients and sampling tubes. We should make continuous efforts to establish safer blood transfusion systems.

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