ERRORS IN TRANSFUSION MEDICINE - DETECTION, ANALYSIS, FREQUENCY, AND PREVENTION

The Mayo Clinic (Rochester, Minn) Division of Transfusion Medicine eva luated the effect of methods of error detection, analysis, and prevent ion on the rate of errors occurring from 1982 through 1992. We defined an error as any deviation from the standard operating procedure. Twen ty-four standard operating procedures were monitored for errors that r elated to donor processing, testing of donor blood, patient testing, a nd transfusion. The estimate of the overall error rate and 95% confide nce interval fluctuated between 20 and 30 per 10(4) procedures. The tr anscription error rate declined from 21 to six per 10(4) procedures as a result of changes to systems using computer-generated labels and ba r codes. We concluded that when errors are recognized, and appropriate system changes are made, these errors can be prevented.