Errors in transfusion medicine. Scope of the problem.

Abstract

Error is ubiquitous whenever humans are involved in a process. Fortunately, most transfusion-related errors are benign. However, the risk of death due to acute hemolytic transfusion reaction rivals that of human immunodeficiency virus transmission and administration of the wrong blood or of blood to the wrong recipient has occurred at many facilities. Most blood misadministration errors are caused by failure to identify the recipient and blood unit adequately, although phlebotomy errors and blood bank errors also contribute. Many errors are multifactorial and may reflect underlying systems defects. Noncompliant specimen labels may be a cue to an increased risk of phlebotomy error. Autologous blood is not immune from error and poses infectious disease risks as well as the risk of hemolytic transfusion reaction; also, perioperatively recovered blood may pose a risk of air embolism if improperly handled.