[Causes of transfusion incidents]

Area of Science:

• Transfusion Medicine
• Patient Safety
• Healthcare Management

Background:

• Transfusion medicine is a critical area of medical research.
• Despite extensive research, fatal transfusion accidents continue to occur.
• Organizational deficiencies are the primary cause of these adverse events.

Purpose of the Study:

• To analyze the root causes of fatal transfusion accidents.
• To identify error-prone stages within the transfusion process.
• To propose a comprehensive transfusion protocol to enhance patient safety.

Main Methods:

• Categorization of transfusion error possibilities into four distinct groups.
• Analysis of errors based on the stages of a complete transfusion process.
• Development of a standardized transfusion protocol.

Main Results:

• Fatal transfusion accidents are predominantly linked to organizational shortcomings.
• Errors can occur at multiple stages of the transfusion pathway.
• The proposed protocol provides a structured approach to minimize risks.

Conclusions:

• Addressing organizational lacks is crucial for preventing fatal transfusion accidents.
• Implementing a standardized transfusion protocol can significantly improve patient outcomes.
• Continuous improvement in transfusion practices is essential for patient safety.