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[Transfusional accident by successive mistakes (author's transl)]
Anesthesie, Analgesie, Reanimation
|January 1, 1981
Summary
A critical blood transfusion error occurred due to multiple procedural mistakes, including misidentification and incorrect blood typing. Despite the errors, the patient recovered fully after receiving appropriate medical intervention.
Area of Science:
- Transfusion Medicine
- Patient Safety
- Clinical Pathology
Background:
- Urgent blood transfusions require strict adherence to protocols to prevent errors.
- Standard blood transfusion procedures involve double-checks for patient and unit identification.
- Potential for errors increases when staffing is reduced or protocols are bypassed.
Observation:
- Discrepancies noted between patient form and blood unit labels.
- Blood group determination performed by a single individual instead of the standard two.
- Patient's prior blood grouping results were not consulted.
- Anesthetist performed an incorrect verification in the operating room.
Findings:
- Multiple errors identified in the blood transfusion process, including patient misidentification and procedural deviations.
- The patient received an incorrect blood unit, yet initially showed no adverse clinical symptoms.
- Delayed onset of oliguria seven hours post-intervention indicated a potential transfusion reaction.
Implications:
- Highlights critical vulnerabilities in transfusion safety protocols under pressure.
- Underscores the importance of rigorous adherence to standard operating procedures, even in urgent situations.
- Emphasizes the need for robust systems to prevent and detect transfusion errors to ensure patient safety and positive outcomes.