A Case of Transfusion Error in a Trauma Patient With Subsequent Root Cause Analysis Leading to Institutional Change

  title={A Case of Transfusion Error in a Trauma Patient With Subsequent Root Cause Analysis Leading to Institutional Change},
  author={S. Clifford and Paul Brian Mick and B. M. Derhake},
  journal={Journal of Investigative Medicine High Impact Case Reports},
A 28-year-old man presented emergently to the operating room following a gun-shot injury to his right groin. Our hospital’s Massive Transfusion Protocol was initiated as the patient entered the operating room actively hemorrhaging and severely hypotensive. During the aggressive resuscitation efforts, the patient was inadvertently transfused 2 units of packed red blood cells intended for another patient due to a series of errors. Fortunately, the incorrect product was compatible, and the patient… Expand
Transfusion Error in the Gynecology Patient: A Case Review with Analysis
This chapter starts with a hypothetical case study of a gynecology patient who underwent emergent hysterectomy with severe hemorrhage managed with an emergency blood transfusion and identifies sources of transfusion-related errors. Expand
Improvement in Blood Transfusion Safety: Using Root Cause Analysis
Objectives: This research aimed at analyzing the adverse events reported related to blood transfusion in one of the large vice-chancellorships of Iran University of Medical Sciences in spring 2018.Expand
A survey of blood transfusion errors in Aichi Prefecture in Japan: Identifying major lapses threatening the safety of transfusion recipients.
  • Masaki Ri, M. Kasai, +10 authors H. Kato
  • Medicine
  • Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis
  • 2020
The results emphasize the importance of education, operational training, and compliance instruction for all members of the medical staff despite advances in electronic devices meant to streamline transfusion procedures. Expand
Medication Errors and Root Causes Analysis: Emerging Views and Practices in King Saud Medical City, Riyadh, Saudi Arabia
Background: Medication errors (MEs) are associated with significant morbidity and mortality, and huge cost worldwide. Medication errors are multifactorial and present in different forms with variableExpand
Smart e-health system for real-time tracking and monitoring of patients, staff and assets for healthcare decision support in Saudi Arabia
Healthcare in Saudi Arabia has been lagging behind the developed countries of the world, due to the insufficient number of healthcare practitioners and the lack of applications of tracking andExpand


Root cause analysis of transfusion error: identifying causes to implement changes
Root cause analyses of one such innocuous appearing error demonstrate how weaknesses in the system can be identified to make necessary changes to achieve transfusion safety. Expand
Root-cause analysis of a potentially sentinel transfusion event: lessons for improvement of patient safety.
It can be concluded that health care organizations should endeavor to provide opportunities to discuss errors and adverse events and introduce preventive measures to find areas where resources need to be allocated to improve patient safety. Expand
Reports of 355 transfusion‐associated deaths: 1976 through 1985
Management systems for transfusion facilities should be created or revised to include the specific identification of personnel eligible to administer transfusions to provide written guidance and appropriate training, and to implement measures that target safe transfusion practices. Expand
Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST)
A qualitative study was undertaken to understand the pretransfusion checking process from the perspective of those who administer blood products and to identify concerns and suggestions to improve safety. Expand
A report of 104 transfusion errors in New York State
The risk of transfusion of ABO‐incompatible blood remains significant, and additional precautions to minimize the likelihood of such events should be considered. Expand
Transfusion errors: causes, incidence, and strategies for prevention
New computer-based technology is available and is very effective in preventing miss-transfusion of blood, which has become one of the leading causes of death related to blood transfusion. Expand
Analysis of ABO discrepancies occurring in 35 French hospitals
The aim of this prospective study was to assess the incidence and root causes of all ABO discrepancies, detected by a central hematology laboratory, in blood samples referred from 35 district hospitals. Expand
Transfusion errors in New York State: an analysis of 10 years' experience
This study characterizes transfusion errors that contribute significantly to adverse outcomes in the blood supply and describes three common types of errors. Expand
Errors in transfusion medicine.
  • D. Stainsby
  • Medicine
  • Anesthesiology clinics of North America
  • 2005
The transfusion chain from the donor to the point of issue from the blood center is highly regulated and secure, and transfusion-transmitted infection is an increasingly rare event. Expand
Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors.
Institution of a computerized bar code-based blood identification system was associated with a large increase in discovered near-miss events. Expand