SHOT Annual Report 2009 - Serious Hazards of Transfusion

COMMENTARY
Each year SHOT emphasises the importance of checking the patient’s identification details at every step of the patient
episode. Errors at admission; incorrect spelling of the patient’s first name or surname, or an incorrect date of birth, can
remain in the patient’s records for the duration of that episode or in some case for years. Often no remedial action is
taken even when a discrepancy is identified by staff, the patient or their carers.
It is crucial that all staff involved in the transfusion process are trained and competent in patient identification procedures
and that a culture of identifying errors and taking remedial action is encouraged. Adopting a proactive approach to
learning from our mistakes can prevent common problems from recurring.
Learning points
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It is imperative that staff are vigilant at all times when participating in the patient identification process,
especially when the patient is admitted, in the laboratory and in clinical areas.
NO wristband (or alternative patient ID) – NO transfusion.
The compatibility form or prescription sheet should never be used as part of the final patient identification
check.
■■ Staff should be extra vigilant in emergency or high risk situations, e.g. when IT systems are down.
7.2 Right Blood Right Patient (RBRP) 65