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"Patient identification errors in pre-transfusion blood sampling ('wrong blood in tube') are a persistent area of risk. These errors can potentially result in life-threatening complications" Oldham (2014).

Abstract:

Introduction: Patient identification errors in pre-transfusion blood sampling (‘wrong blood in tube’) are a persistent area of risk. These errors can potentially result in life-threatening complications. Current measures to address root causes of incidents and near misses have not resolved this problem and there is a need to look afresh at this issue.

Project purpose: This narrative review of the literature is part of a wider system-improvement project designed to explore and seek a better understanding of the factors that contribute to transfusion sampling error as a prerequisite to examining current and potential approaches to error reduction.

Search strategy: A broad search of the literature was undertaken to identify themes relating to this phenomenon.

Key discoveries: Two key themes emerged from the literature. Firstly, despite multi-faceted causes of error, the consistent element is the ever-present potential for human error. Secondly, current focus on error prevention could potentially be augmented with greater attention to error recovery.

Conclusions: Exploring ways in which clinical staff taking samples might learn how to better identify their own errors is proposed to add to current safety initiatives.

Reference:

Oldham, J. (2014) Blood transfusion sampling and a greater role for error recovery. British Journal of Nursing. 23(8), Supplement, p.S28-S34.