Transfusion errors in New York State: an analysis of 10 years' experience

Authors

  • Jeanne V. Linden,

    1. From the Blood and Tissue Resources Program, Wadsworth Center, New York State Department of Health, Albany, New York; and the Departments of Medicine and of Community Medicine and Health Care, University of Connecticut School of Medicine, Farmington, Connecticut.
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  • Kathleen Wagner,

    1. From the Blood and Tissue Resources Program, Wadsworth Center, New York State Department of Health, Albany, New York; and the Departments of Medicine and of Community Medicine and Health Care, University of Connecticut School of Medicine, Farmington, Connecticut.
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  • Anthony E. Voytovich,

    1. From the Blood and Tissue Resources Program, Wadsworth Center, New York State Department of Health, Albany, New York; and the Departments of Medicine and of Community Medicine and Health Care, University of Connecticut School of Medicine, Farmington, Connecticut.
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  • Joseph Sheehan

    1. From the Blood and Tissue Resources Program, Wadsworth Center, New York State Department of Health, Albany, New York; and the Departments of Medicine and of Community Medicine and Health Care, University of Connecticut School of Medicine, Farmington, Connecticut.
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Address reprint requests to: Jeanne V. Linden, MD, MPH, Director, Blood and Tissue Resources Program, Wadsworth Center, New York State Department of Health, P.O. Box 509, Empire State Plaza, Albany, NY 12201-0509; e-mail: JVL01@health.state.ny.us.

Abstract

BACKGROUND: While public focus is on the risk of infectious disease from the blood supply, transfusion errors also contribute significantly to adverse outcomes. This study characterizes such errors.

STUDY DESIGN AND METHODS: The New York State Department of Health mandates the reporting of transfusion errors by the approximately 256 transfusion services licensed to operate in the state. Each incident from 1990 through 1998 that resulted in administration of blood to other than the intended patient or the issuance of blood of incorrect ABO or Rh group for transfusion was analyzed.

RESULTS: Erroneous administration was observed for 1 of 19,000 RBC units administered. Half of these events occurred outside the blood bank (administration to the wrong recipient, 38%; phlebotomy errors, 13%). Isolated blood bank errors, including testing of the wrong specimen, transcription errors, and issuance of the wrong unit, were responsible for 29 percent of events. Many events (15%) involved multiple errors; the most common was failure to detect at the bedside that an incorrect unit had been issued.

CONCLUSION: Transfusion error continues to be a significant risk. Most errors result from human actions and thus may be preventable. The majority of events occur outside the blood bank, which suggests that hospitalwide efforts at prevention may be required.

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