Transfusion errors and their prevention

Abstract

Although the current risks of acquiring viral transmission through blood components and products are very small, mistransfusion, in which a blood unit is incorrectly administered to a non‐designated recipient, remains the most common type of error in transfusion practice. ABO‐incompatible blood transfusion attributable to the incorrect identification (ID) of the patient or the blood unit is one of the most serious transfusion hazards. Many studies revealed that transfusion errors occur frequently in clinical areas, with the most common error being failure to perform the final patient ID check at the bedside. Thus, the pretransfusion bedside check is the most critical step for the prevention of mistransfusion. Machine‐readable ID technology, especially a bar code‐based ID system, is ideally suited to bedside check requirements. Our experience at the Juntendo University Hospital shows that the bar code‐based ID system has worked well over a 7‐year period on a hospital‐wide basis, and approximately 70 000 blood components have been transfused without a single mistransfusion. The overall rate of compliance with ‘second’ electronic bedside checking for blood components was 99%. Human error was the most frequent cause of errors leading to the failure of the bedside bar code ID check. The bar code‐based ID system has become applicable to the bedside pretransfusion check for paediatric transfusion, i.e. blood dispensed in syringes, and preoperative autologous blood donation, as well as regular allogeneic blood transfusion. If we want to reduce the risk of mistransfusion to improve transfusion safety, we have to address the issue at the hospital level, with a system‐based approach.