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Transfusion "Slip".
Kaplan HS. AHRQ WebM&M [serial online]. February 2004.
Blood typing tubes for a married couple brought to an emergency department after a trauma are labeled with the opposite stickers. By coincidence, the wife’s blood type was already on file. An alert blood-bank technologist catches the mistake.
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Resource Type
Commentary
Setting of Care
Emergency Departments
Target Audience
Health Care Providers
Non-Health Care Professionals
Clinical Area
Emergency Medicine
General Internal Medicine
Hospital Medicine
Pathology & Laboratory Medicine
Safety Target
Identification Errors
Transfusion Complications
Error Types
Noncognitive Errors ("Slips & Lapses")
Latent Errors
Near Miss
Approach to Improving Safety
Audit and Feedback
Continuous Quality Improvement
Forcing Functions
Bar Coding and Radiofrequency ID Tagging
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)