Wrong blood in theatre.

Abstract

Transfusion of the wrong blood to patients is the commonest adverse event reported to the Serious Hazards of Transfusion (SHOT) reporting scheme and can be fatal if there is ABO incompatibility. Failure to identify the correct patient, or the correct unit of blood for the patient at the bedside, prior to administering blood, is the commonest source of error [1]. In a recent case, several units of blood were obtained for a patient in theatre and were checked by staff to establish that the patient identification details on the units of blood corresponded to those on the patient. All units were placed in the theatre refrigerator prior to use. An Operating Department Assistant later collected what he believed was one of these units but in fact it was a unit intended for another patient. The anaesthetist did not carry out a final bedside check of the patient identification details on the unit against those on the patient as he had checked all the units earlier. The patient was group B and received group A blood. (personal communication – Dr P Hewitt) It is not uncommon practice in operating theatres for patient identification checks on units of blood to be carried out at the start of surgery to ascertain that blood is available quickly if required: it is then stored in the theatre transfusion refrigerator. The British Committee for Standards in Haematology guidelines for the administration of blood and blood components state that the patient's surname, forename, date of birth and unique patient identification number should be checked on the blood unit, the accompanying compatibility form and the patient's wristband, to ensure that they tally before commencing transfusion of blood [2]. To avoid an error such as in this case, there must be a final comparison of the patient identification details on each unit of blood against the patient's identification details immediately before the blood is connected. Responsibility for this should lie with the person who is connecting the unit of blood to the patient. We are aware of several other hospitals in which this final check is not routine (personal communication – Fiona Regan). In keeping with the clinical governance principle of preventing similar future incidents, we propose that all hospitals should promptly review their procedures to ensure that such a final patient identification check is carried out at the point of connecting a unit of blood to a patient. The authors wish to clarify that this incident occurred at an unnamed Trust, and not at any hospital at which we are employed.