Jane Oldham1. 1. Transfusion Practitioner, NHS Lothian and Member, Better Blood Transfusion team, NHS National Services Scotland.
Abstract
INTRODUCTION: Patient identification errors in pre-transfusion blood sampling ('wrong blood in tube') are a persistent area of risk. These errors can potentially result in life-threatening complications. Current measures to address root causes of incidents and near misses have not resolved this problem and there is a need to look afresh at this issue. PROJECT PURPOSE: This narrative review of the literature is part of a wider system-improvement project designed to explore and seek a better understanding of the factors that contribute to transfusion sampling error as a prerequisite to examining current and potential approaches to error reduction. SEARCH STRATEGY: A broad search of the literature was undertaken to identify themes relating to this phenomenon. KEY DISCOVERIES: Two key themes emerged from the literature. Firstly, despite multi-faceted causes of error, the consistent element is the ever-present potential for human error. Secondly, current focus on error prevention could potentially be augmented with greater attention to error recovery. CONCLUSIONS: Exploring ways in which clinical staff taking samples might learn how to better identify their own errors is proposed to add to current safety initiatives.
INTRODUCTION:Patient identification errors in pre-transfusion blood sampling ('wrong blood in tube') are a persistent area of risk. These errors can potentially result in life-threatening complications. Current measures to address root causes of incidents and near misses have not resolved this problem and there is a need to look afresh at this issue. PROJECT PURPOSE: This narrative review of the literature is part of a wider system-improvement project designed to explore and seek a better understanding of the factors that contribute to transfusion sampling error as a prerequisite to examining current and potential approaches to error reduction. SEARCH STRATEGY: A broad search of the literature was undertaken to identify themes relating to this phenomenon. KEY DISCOVERIES: Two key themes emerged from the literature. Firstly, despite multi-faceted causes of error, the consistent element is the ever-present potential for human error. Secondly, current focus on error prevention could potentially be augmented with greater attention to error recovery. CONCLUSIONS: Exploring ways in which clinical staff taking samples might learn how to better identify their own errors is proposed to add to current safety initiatives.
Authors: Thomas Frietsch; Daffyd Thomas; Michael Schöler; Birgit Fleiter; Martin Schipplick; Michael Spannagl; Ralf Knels; Xuan Nguyen Journal: Transfus Med Hemother Date: 2017-03-16 Impact factor: 3.747