title: Error reporting in transfusion medicine at a tertiary care centre: a patient safety initiative.
abstract: BACKGROUND
  Errors in the transfusion process can compromise patient safety. A study was undertaken at our center to identify the errors in the transfusion process and their causes in order to reduce their occurrence by corrective and preventive actions.
  
  
  METHODS
  All near miss, no harm events and adverse events reported in the 'transfusion process' during 1 year study period were recorded, classified and analyzed at a tertiary care teaching hospital in North India.
  
  
  RESULTS
  In total, 285 transfusion related events were reported during the study period. Of these, there were four adverse (1.5%), 10 no harm (3.5%) and 271 (95%) near miss events. Incorrect blood component transfusion rate was 1 in 6031 component units. ABO incompatible transfusion rate was one in 15,077 component units issued or one in 26,200 PRBC units issued and acute hemolytic transfusion reaction due to ABO incompatible transfusion was 1 in 60,309 component units issued. Fifty-three percent of the antecedent near miss events were bedside events. Patient sample handling errors were the single largest category of errors (n=94, 33%) followed by errors in labeling and blood component handling and storage in user areas.
  
  
  CONCLUSIONS
  The actual and near miss event data obtained through this initiative provided us with clear evidence about latent defects and critical points in the transfusion process so that corrective and preventive actions could be taken to reduce errors and improve transfusion safety.
authors.affiliation: Department of Transfusion Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India. pelhence@sgpgi.ac.in
authors.forename: Priti
authors.initials: P
authors.lastname: Elhence
authors.forename: Veena
authors.initials: V
authors.lastname: Shenoy
authors.forename: Anupam
authors.initials: A
authors.lastname: Verma
authors.forename: Deepti
authors.initials: D
authors.lastname: Sachan
mesh_terms: D001803:Blood Transfusion / Q000706:statistics & numerical data*; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D061214:Patient Safety / Q000706:statistics & numerical data*; D010865:Pilot Projects; D058028:Research Report; D062606:Tertiary Care Centers / Q000706:statistics & numerical data*; D065227:Transfusion Reaction