title: [Analyses of 6 misidentifications in blood sampling in our hospital].
abstract: The initial step of blood transfusion therapy is blood type grouping. ABO-mismatch blood transfusion results in serious adverse effects. 6 incidents in the process of blood type identification, which were caused by misidentification in blood sampling, have experienced in our hospital since October, 2006 to September 2009. We retrospectively examined these incidents, and discussed the reasons and countermeasures. All of 6 incidents were caused by busy residents or nurses during busy hours such as early in the morning or in the emergency. To prevent these incidents, staffs of transfusion unit announced what we have to take care in sampling blood and tied alert tags to sampling tubes. Moreover, we have recently introduced crosschecking computer systems between patients and sampling tubes. We should make continuous efforts to establish safer blood transfusion systems.
authors.affiliation: Transfusion and Cell Therapy, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan. chiaki@hama-med.ac.jp
authors.forename: Chiaki
authors.initials: C
authors.lastname: Yamada
authors.forename: Harumi
authors.initials: H
authors.lastname: Fujiwara
authors.forename: Naoko
authors.initials: N
authors.lastname: Ogawa
authors.forename: Yui
authors.initials: Y
authors.lastname: Funai
authors.forename: Hiroki
authors.initials: H
authors.lastname: Shibata
authors.forename: Hiroko
authors.initials: H
authors.lastname: Watanabe
authors.forename: Makoto
authors.initials: M
authors.lastname: Kaneko
authors.forename: Akihiro
authors.initials: A
authors.lastname: Takeshita
mesh_terms: D001788:Blood Grouping and Crossmatching; D006801:Humans; D010355:Patient Identification Systems / Q000592:standards*; D012189:Retrospective Studies