To err is human: adverse events in blood transfusion

Human error has often been cited as a primary cause or contributing factor in disasters and accidents in industries as diverse as nuclear power, aviation and of course medicine. Furthermore, in the field of blood transfusion, the Serious Hazards of Transfusion (SHOT) scheme has consistently commented that human errors can occur at all stages of the transfusion process, be they at the blood sampling stage, at the bedside or even within the transfusion laboratory. It was therefore appropriate that the subject of human error was chosen as the theme for the latest joint meeting of the UK NEQAS (BTLP) and BBTS SIG groups, particularly as the latest SHOT annual report (2011) had again cited human error in many of the serious adverse events reported to the Medicines and Healthcare products Regulatory Agency (MHRA), over 50% of which were deemed preventable.

Whose blood is it anyway?
‘Whose Blood is it Anyway?’ was the intriguing title of the first session, beginning with transfusion quality coordinator Anne Varey, who presented the background to, and data from, the recent national audit of transfusion sample labelling. Anne considered that audit of this area is essential, as not only is accurate patient identification a critical safety issue in healthcare, but if mistakes are made in this area then it has the potential to cause serious harm to patients due to inappropriate treatment or failure to treat based on results from the wrong samples.

Outlining the main aims of the audit, which was to identify the causes of ‘wrong blood in tube’ (WBIT) incidents and to reduce blood sample labelling errors, Anne explained the audit design, which took the form of a national three-month study into the ‘who’, ‘why’, ‘where’ and ‘how’ of transfusion sample rejections by hospital blood banks. A total of 272 sites participated in the audit, which eventually revealed some fascinating data on sample mislabelling.