Errors in transfusion medicine are not only misidentifications of the recipient, but also pre-analytical and analytical errors.

摘要

Errors in blood administration are the result of mistakes occurring in a complex process (1). Like administration of any other drug, our goals are the: right drug, right patient, right time, right dose and right route (2). In the field of transfusion medicine, the most important issue is a unique blood unit for a unique patient. Not all blood units (i.e., red cell concentrates) are compatible with all patients. In his review (3), Franchini does a good analysis of the core problem which is correct patient identification. In fact, he correctly identifies tools that avoid the major cause of incorrect transfusion (4). The implementation of hemovigilance systems is an effective, but not definitive method for preventing transfusion reactions due to ABO incompatibility (5). However, the use of positive identification devices for bags and patients are recommended (6). Technological approaches are very important to reduce errors in this field. Devices that can read data can replace repetitive and tedious pre-transfusion procedures, thus preventing possible errors caused by inattention. Devices designed to aid in patient identification include identification bracelets with alphanumeric codes, barcode bracelets read by handheld scanners and bedside wireless computers, radiofrequency identification systems and mobile fingerprint sensors. These methods to ensure accuracy and precision in the identification of patients and transfusion units are not more expensive. The primary barrier to the widespread introduction of these new technologies in the hospital setting is not just cost, instead implementation of new hospital procedures requires relevant resources, time as well as money. If we really want to improve transfusion safety, we need to address these issues at the hospital using a systems-based approach (7).