SHOT Annual Report 2009 - Serious Hazards of Transfusion

7.2 Right Blood Right Patient (RBRP)
As in previous years reporters have been given the opportunity to separately submit incidents where the right blood
was transfused to the right patient despite an error or errors that should have led to the unit being rejected. These
errors do not fit the definition of IBCT but are instructive nevertheless. They are not included in the overall numbers of
IBCT cases. There are 143 cases in this 2009 report, representing a 32% increase in the number of reports in the RBRP
category from 2008. On review 3 were transferred out to the IBCT section and 1 to the I&U section. This section describes
the findings from 143 completed questionnaires.
Table 24
Right blood to right patient episodes n = 143
Elements that were wrong on blood packs, documentation, identity bands, etc.
2008
Incidents
2009
Incidents
Name alone or with other elements 24 43
Date of birth alone or with other elements 32 33
Transposed labels on 2 or more units for the same patient 20 31
Hospital or NHS Number 10 17
Donation/Pack Number 8 3
Miscellaneous
Failure to use address as defined in hospital policy 1 2
Wristband missing or wrong wristband in place at final patient checking procedure 0 4
Incomplete or no Identification Tag issued with component 3 4
Incomplete issue procedures undertaken 0 3
Incomplete Request Form 0 2
Incorrect ‘T’ Number 0 1
Wrong expiry date on label (IT error) 1 0
Incorrect assigned unit supplied, e.g. paedipak 2 0
Total 101 143
As highlighted in previous years, had the correct checking procedures been undertaken during the patient’s admission
procedure, both in the laboratory and during the final patient identity check, all these errors could have been prevented.
Staff have a personal and professional responsibility to ensure they adhere to the correct patient identification procedures
at all times.
This report highlights a number of cases from the clinical and laboratory areas that demonstrate how errors went
undetected despite staff having a number of opportunities to identify them and take corrective actions.
7.2 Right Blood Right Patient (RBRP) 63