Over half of cases of transfusion error involve giving the wrong blood

This week sees publication of the findings of the second annual report of the Serious Hazards of Transfusion (SHOT) initiative (p 16), a confidential system for reporting deaths and major complications from transfusion. The key finding after analysis of the first 366 reports received was that over half of cases involved administration of the wrong unit of blood. Most of these cases involved procedural errors. Infections transmitted by transfusion were rare, with only 12 cases reported. One, however, was transmision of HIV, the first for over a decade in the United Kingdom. Further improvements in transfusion safety will depend on staff training, better methods of identification, and prioritisation of resources towards problem areas.

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Relevant Article

Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports

L M Williamson, S Lowe, E M Love, H Cohen, K Soldan, D B L McClelland, P Skacel, and J A J Barbara
BMJ 1999 319: 16-19. [Abstract] [Full Text] [PDF]