Transfusion errors: causes and effects.

Abstract

HUMAN error is an ubiquitous accompaniment of human activity. In the vast majority of daily circumstances the results of error are, at most, annoying or inconvenient. Some classic examples are leaving car keys in the ignition or wearing mismatched socks. However, in such errorcritical fields as aviation, nuclear power, and medicine, even though the vast majority of errors are and contained, they have a greater potential for catastrophic results. It has been estimated that as many as one medication error per patient per day occurs in hospitals in the United States. I Most of these errors do not affect patients ar lengthen the duration of their hospitalization, although some do have serious, and even fatal effects. In transfusion medicine, there is a similar preponderance of benign error. However, because of preformed antibodies in the ABO system, and their potential for an acute hemolytic transfusion reaction, an active error such as misidentification of the patient or specimen has a magnified potential for harm because of its possible combination with the pervasive potential of blood group incompatibility . The term latent error is used in contrast to the term active error, the effects of which are immediately appreciated. 2 The latent error may exist within the system for varying periods, typically dormant and unnoticed unti!, when combined with another factor, such as an active error, it causes an accident. Active errors are most often committed by line personnel. Latent errors reflect the environment in which an error occurs. They are characteristically managerial in origin and are often caused by policy decisions or system design. Recognition that incompatible blood can cause a serious or even fatal reaction dates to the early days of transfusion. In fact, the earliest report of a transfusion reaction is attributed to Denys in 1667,3 long before identification of blood groups enabled the procedure to be performed on a routine basis. In 1942, Kilduffe and DeBakey published data collating the collective experience of several investigators over the 24-year period of 1917 to 1941, citing a risk for hemolytic transfusion reaction of 1 in 541 transfusions (80/43,284), and a mortality rate for transfusion reaction of 58%, leading to a risk of death from transfusion of 1 in