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Comparing near misses with actual mistransfusion events: a more accurate reflection of transfusion errors
Author(s) -
J. Ibojie,
S. J. Urbaniak
Publication year - 2000
Publication title -
british journal of haematology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.907
H-Index - 186
eISSN - 1365-2141
pISSN - 0007-1048
DOI - 10.1046/j.1365-2141.2000.01876.x
Subject(s) - phlebotomy , medicine , near miss , transfusion reaction , emergency medicine , blood transfusion , blood bank , medical emergency , surgery , reliability engineering , engineering
In a retrospective review of transfusion errors in a large teaching hospital, we found the true incidence of errors to be at least four times the actual mistransfusion events detected. Seventy‐five per cent of the errors were detected as near misses. The mistransfusions equated to 1/8610 compatibility procedures, and 1/27 007 units of blood issued, whereas the number of true transfusion errors equates to 1/2153 compatibility procedures and 1/6752 units of blood issued. The major error‐prone activities included patient identification at phlebotomy and the final infusion of the blood product at the bedside. Of the cases, 95.2% were due to non‐compliance with existing guidelines. Potential disasters were avoided only by the vigilance of the blood bank staff and the systems in place to detect errors.