Haemovigilance Annual Report 2021

The discovery, processing and reporting of transfusion errors is a sign of a functioning quality
management system – we would expressly like to thank all reporters for their commitment
to improving transfusion safety. A structured incident analysis should be performed,
taking all the process factors into account. 51% of the IBCT reports in 2021 identified “human
error” (failure to follow an existing SOP, human error, individual error) as the main
cause of the incident. However, in most incidents there are other factors in the process which
increase the likelihood of an error being made, and these present an opportunity to improve
safety. We would like to mention some of the factors which were involved in the above
examples of IBCT-WCT for illustrative purposes.
Factors which increase the likelihood of errors
Temporary patient identification
Emergency situations in which it is not possible to identify the patient completely are always
a risk. The use solely of numerical codes and consecutive numerical codes – which differ only
slightly from each other – has an increased potential for causing mix-ups. Possible safety precautions
could include the assignment of random names (using a pre-defined system), temporary
patient identification consisting of numbers and letters (where technically possible) or the use of
non-consecutive numerical codes. A combination of a number with additional information (e.g.
room number, invented first names) can also increase safety.
Oral prescriptions
Oral prescriptions are part of clinical life. They must be seen as a contributing factor in two of the
IBCT-WCT. Written prescriptions should be used wherever possible – options for issuing written
prescriptions should be easily and rapidly available.
Interfaces
There is a risk of a transmission error occurring every time prescriptions and information are
transferred. In an IBCT-WCT the transfer of an electronic prescription from the clinical information
system to a paper form and subsequently into another electronic system (laboratory information
system) must be viewed as the source of the error. Direct information transfer can improve transfusion
safety and should therefore be the goal.
Transfusion errors / IBCT and Near Miss | Haemovigilance Annual Report 2021
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