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This Safer Practice Notice sets out measures to improve the safety of blood transfusions, including photo identification cards for regular patients and electronic tracking systems for patients and blood.
Blood transfusions involve a complex sequence of activities and, to ensure the right patient receives the right blood, there must be strict checking procedures in place at each stage. Administering the wrong blood type (ABO incompatibility) is the most serious outcome of error during transfusions. Most of these incidents are due to the failure of the final identity checks carried out between the patient (at thepatient's side) and the blood to be transfused.
SHOT data have shown that between 1996 and 2004, five patients died as a direct result of being given ABO incompatible blood. ABO incompatibility contributed to the deaths of a further nine patients and caused major morbidity in 54 patients.
Actions for healthcare organisations include:
Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.
A series of documents is available on developing competencies for staff involved in blood transfusions.
