Error management of emergency transfusions: a surveillance system to detect safety risks in day to day practice

Transfus Apher Sci. 2006 Oct;35(2):125-30. doi: 10.1016/j.transci.2006.06.001. Epub 2006 Oct 12.

Abstract

Acute hemolysis due to AB0-incompatibility caused by transfusion of red blood cell concentrates (RBCC) to the wrong recipient is one of the major causes of transfusion-related death. As part of our policy to improve quality and safety in emergency transfusion, we have developed a standardized surveillance system for supplying RBCC in emergency situations. This surveillance system involves the implementation of a standardized set of basic data transmitted from the requesting unit to the blood bank by phone and a scoring system to check for compliance with guidelines and errors in daily routines. Communication deficiencies and delayed pretransfusion sampling were the most common errors.

MeSH terms

  • Blood Group Incompatibility / prevention & control*
  • Erythrocyte Transfusion*
  • Female
  • Guideline Adherence
  • Humans
  • Information Management*
  • Male
  • Practice Guidelines as Topic
  • Retrospective Studies
  • Risk Management
  • Safety Management*