title: [Errors of red cell concentrates recipients: method of analysis using the adverse events notified to the hemovigilance network in 2009].
abstract: BACKGROUND
  Among the adverse events in the blood transfusion process, transfusion to a "wrong" patient is potentially dangerous, as it can lead to an adverse reaction at least in case of ABO incompatible red cell concentrate.
  
  
  METHODS
  The "Root Cause Analysis" working party of the National Hemovigilance Commission developed a tool to collect this type of adverse event, and tested it on a sample of 43 cases involving red cell concentrates notified between March, 2009 and February, 2010.
  
  
  RESULTS
  One hundred and nine failures of a step in the transfusion process were observed, i.e. 2.5 failures per adverse event. Failures may occur early in the process. However, they are mainly found at the time of issuing of the blood component, and further, in the clinical ward. How the failure is eventually detected is not always described when the blood component has been fully transfused, in contrast with the cases where actual transfusion to the wrong patient has been prevented. Knowing the way of failure detection enables an objective approach of the efficacy of the numerous existing safety measures. In this sample, bedside controls (documents check as well as the use of anti-A and anti-B reagents with patient's blood and red cell concentrates) detected the failure in three cases out of 34, which were not detected before, showing an efficacy similar to the administrative control done at reception in the clinical ward.
  
  
  CONCLUSIONS
  The document, set up to analyse step by step these cases of patient errors, will be used in the future to analyse all similar cases, not only with red cell concentrates, but also with platelet concentrates and fresh frozen plasma, ultimately in order to improve their prevention.
authors.affiliation: Département d'anesthésie-réanimation, hôpital d'instruction des armées du Val-de-Grâce, Paris cedex, France.
authors.forename: E
authors.initials: E
authors.lastname: Falzone
authors.forename: Y
authors.initials: Y
authors.lastname: Auroy
authors.forename: C
authors.initials: C
authors.lastname: Hoffmann
authors.forename: I
authors.initials: I
authors.lastname: Sandid
authors.forename: M
authors.initials: M
authors.lastname: Carlier
authors.forename: D
authors.initials: D
authors.lastname: Benhamou
authors.forename: G
authors.initials: G
authors.lastname: Andreu
authors.forename: A
authors.initials: A
authors.lastname: Lienhart
mesh_terms: D058731:Blood Safety; D017707:Erythrocyte Transfusion; D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data*; D018579:Patient Selection