Sources of preventable errors related to transfusion.
OBJECTIVE
Transfusion errors always remain under-reported owing to a lack of awareness about transfusion-related adverse events among the hospital staff and an inadequate feedback system in most of the transfusion centres. This article reports the results obtained from a study carried out to investigate the sources and types of errors in our tertiary care hospital.


METHODS
The errors reported by the blood bank staff (i.e. reception counter clerical and technical staff) and the residents in charge of the patient, were studied over a period of 1 year (from May 1998 to April 1999) and classified based on the site of occurrence.


RESULTS
A total of 123 errors were detected over the 1-year study period. Of these 123 errors, 107 (86.99%) occurred outside the blood bank and 16 (13%) in the blood bank.


CONCLUSIONS
Errors occur most frequently outside the blood bank, and the bedside of the patient is the main location.
Sharma
R R
RR
Department of Transfusion Medicine, Post Graduate Institute of Medical, Education and Research, Chandigarh, India.
Kumar
S
S
Agnihotri
S K
SK
D001771:Blood Banks / Q000592:standards; D001803:Blood Transfusion / Q000592:standards*; D006761:Hospitals / Q000592:standards; D006801:Humans; D007194:India; D019300:Medical Errors / Q000517:prevention & control* / Q000592:standards; D010355:Patient Identification Systems / Q000592:standards; D012308:Risk Management; D013048:Specimen Handling / Q000592:standards