Fatal blood transfusion reactions. An analysis.

Abstract

This analysis of fatal blood transfusion reactions includes statistics from the Bureau of Biologics provided through the Freedom of Information Act. The study of 126 reported transfusion fatalities occurring between 1976 and 1980 showed that the staff certifying compatibility and the personnel administering the blood have an approximately equal share of the problems. Resolution of blood bag labeling errors through automation leaves patient identification as a major obstacle to those certifying compatibility and the transfusionists. The patient identification wrist band is excellent. However, professional staff do not always utilize this information, relying on memory. In addition, professional staff do not always collate adequately the information on the blood transfusion request form, the blood bag label, and the wrist band of the patient to be transfused. Electronic collation is discussed as a means to identify discrepancies prior to transfusion. The special problem of staff dealing with a time-limited, life-threatening emergency is described and six critical areas related to the problem of fatal transfusion reactions are suggested for further analysis.