Human error: the persisting risk of blood transfusion: a report of five cases.
It is common experience that virus transmission, particularly transmission of the human immunodeficiency virus (HIV), is a principal concern of patients and physicians regarding blood transfusion (1). Many physicians are probably unaware that transfusion-transmitted HIV infection is approximately 50 to 100 times less likely to occur than transfusion error (2-4). This misconception may have been encouraged by the scarcity of reports on transfusion error relative to the tremendous public attention focused on HIV infection. We present five cases illustrating how anesthesiologists, intensivists, and emergency physicians are particularly vulnerable to the risk of administering blood to the wrong recipient. All five cases were collected during a 4-yr period. Transfused units of packed red cells totaled approximately 50,000 U during this period in our department.


CONCLUSIONS
Human error leading to the transfusion of blood to an unintended recipient is a major source of transfusion-related fatalities. We report five cases that highlight some specific areas in which transfusion error is likely to occur.
Krombach
Jens
J
Department of Anesthesiology, University of Cologne, Germany. krombach@netcologne.de
Kampe
Sandra
S
Gathof
Birgit S
BS
Diefenbach
Christoph
C
Kasper
Stefan-Mario
SM
D001788:Blood Grouping and Crossmatching; D001800:Blood Specimen Collection; D001803:Blood Transfusion; D006801:Humans; D019300:Medical Errors