BEDSIDE TRANSFUSION ERRORS - A PROSPECTIVE SURVEY BY THE BELGIUM SANGUIS GROUP

The true incidence of bedside transfusion errors, i.e. those happening when blood products have left the blood bank, is underestimated becau se published figures rely on reporting of clinically relevant events o r on indirect methods. The SANGUIS project assessing blood practice in a prospective and randomized fashion for 6 elective surgical procedur es gave the opportunity to trace all transfused units and to identify steps at risk during blood delivery in surgery. We considered transfus ion of a wrong unit as a major error and poor execution or documentati on as a recording error. Over 15 months, 808 patients out of 1,448 wer e transfused with 3,485 units. A total of 165 errors were found after blood products had left the blood banks. Seven were misidentifications (0.74% of patients, 0.2% of units). Eight other major errors occurred in 4 (0.5%) patients. Major errors occurred during nonemergency situa tions, in wards or intensive care units. The remaining ('recording') 1 50 errors consisted of misrecordings (61), mislabellings (6), or failu res to document transfusions in the medical records (83). All errors w ere uneventful except one misidentification which induced a transient, yet unreported, reaction. The 'descending' inquiry method used for th is study showed that most errors pass unnoticed and are therefore not reported. Measurement of error rates may constitute an important quali ty indicator. Retrospective information of this survey to the concerne d staff people provided an impetus to take adequate measures to reduce these bedside errors.