Sources of preventable errors related to transfusion

Vox Sang. 2001 Jul;81(1):37-41. doi: 10.1046/j.1423-0410.2001.00057.x.

Abstract

Background and objectives: Transfusion errors always remain under-reported owing to a lack of awareness about transfusion-related adverse events among the hospital staff and an inadequate feedback system in most of the transfusion centres. This article reports the results obtained from a study carried out to investigate the sources and types of errors in our tertiary care hospital.

Materials and methods: The errors reported by the blood bank staff (i.e. reception counter clerical and technical staff) and the residents in charge of the patient, were studied over a period of 1 year (from May 1998 to April 1999) and classified based on the site of occurrence.

Results: A total of 123 errors were detected over the 1-year study period. Of these 123 errors, 107 (86.99%) occurred outside the blood bank and 16 (13%) in the blood bank.

Conclusion: Errors occur most frequently outside the blood bank, and the bedside of the patient is the main location.

MeSH terms

  • Blood Banks / standards
  • Blood Transfusion / standards*
  • Hospitals / standards
  • Humans
  • India
  • Medical Errors / prevention & control*
  • Medical Errors / standards
  • Patient Identification Systems / standards
  • Risk Management
  • Specimen Handling / standards