Errors in blood transfusion in Britain: survey of hospital haematology departments

McClelland, D. B. L.; Phillips, Peter

doi:10.1136/bmj.308.6938.1205

Cited by 96 publications

(75 citation statements)

References 3 publications

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“…Until 1996 blood transfusion was not covered by either a confidential inquiry or the yellow card system of the Committee of Safety of Medicines. Perception of transfusion safety focuses on the diminishing risk of viral transmission, while the risk of ABO incompatible transfusion due to errors in blood or patient identification remains a threat 1 2. To analyse the residual risks of transfusion, a confidential voluntary reporting system for major transfusion events—serious hazards of transfusion (SHOT)—affiliated to the Royal College of Pathologists was launched in 1996.…”

Section: Introductionmentioning

confidence: 99%

Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports

Williamson

Lowe

Love

et al. 1999

BMJ

Self Cite

318

215

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reprovision programmes in Britain, provided that these are well planned and well resourced. ConclusionOur findings dispel some of the common concerns and myths associated with "care in the community" patients and provide robust evidence that community care has worked well for the former patients of psychiatric hospitals, most of whom are currently living in the community and posing minimal risk to themselves and the public. In light of this, a change towards institutional care is not a rational policy.We thank the research workers who have contributed to the collection of the data, the patients, and the hospital and community staff. This paper is designated the TAPS project 45.Contributors: NT participated in data collection, analysis, interpretation, and drafting the paper. JL conceived and designed the Team for the Assessment of Psychiatric Services (TAPS) project and has been the director of the research team for the past 13 years. He helped to draft and edit this paper. GG participated in the analysis and interpretation of the mortality data. He also computerised the assessment tools used by TAPS. NT and JL will act as guarantors for the paper.Funding: The Team for the Assessment of Psychiatric Services (TAPS) is funded by the Department of Health, North Thames Regional Health Authority, and the Gatsby Foundation. It is administered through the Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, London.Competing interests: The TAPS project was largely funded by the Department of Health. This, and previous TAPS papers, were sent for comments to the Department of Health before submission. However, all papers, including this one, were drafted without administrative intervention or scrutiny of any kind. The opinions expressed do not necessarily reflect the policy of the Department of Health. AbstractObjective To receive and collate reports of death or major complications of transfusion of blood or components.

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Section: Introductionmentioning

confidence: 99%

Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports

Williamson

Lowe

Love

et al. 1999

BMJ

Self Cite

318

215

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“…The ultimate objective of the blood transfusion laboratory is the provision of safe and appropriate blood and blood components to patients (McClelland & Phillips, 1994). Despite the focus on transfusion-transmitted diseases, more avoidable morbidity and mortality occurs as a result of transfusion of incorrect blood components (McClelland et al, 1996;AuBuchon & Kruskall, 1997).…”

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confidence: 99%

Comparing near misses with actual mistransfusion events: a more accurate reflection of transfusion errors

Ibojie

Urbaniak

2000

Br J Haematol

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Summary. In a retrospective review of transfusion errors in a large teaching hospital, we found the true incidence of errors to be at least four times the actual mistransfusion events detected. Seventy-®ve per cent of the errors were detected as near misses. The mistransfusions equated to 1/8610 compatibility procedures, and 1/27 007 units of blood issued, whereas the number of true transfusion errors equates to 1/2153 compatibility procedures and 1/6752 units of blood issued. The major error-prone activities included patient identi®cation at phlebotomy and the ®nal infusion of the blood product at the bedside. Of the cases, 95´2% were due to non-compliance with existing guidelines. Potential disasters were avoided only by the vigilance of the blood bank staff and the systems in place to detect errors.

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“…A British survey revealed that episodes where wrong blood is given to a patient as a result of poor patient identification may complicate as many as 1 in 30 000 transfusions 3. Mortality is minimised, firstly, because the distribution of blood groups in the British population means that two thirds of “wrong” transfusions are by chance ABO compatible and, secondly, by the fact that only 1 in 10 ABO incompatible transfusions is fatal 4.…”

Section: A New Surveillance System For Transfusion Hazardsmentioning

confidence: 99%

A SHOT in the arm for safer blood transfusion

Williamson

Heptonstall

Soldan

1996

BMJ

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Errors in blood transfusion in Britain: survey of hospital haematology departments

Cited by 96 publications

References 3 publications

Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports

Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports

Comparing near misses with actual mistransfusion events: a more accurate reflection of transfusion errors

A SHOT in the arm for safer blood transfusion

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