Journal Article
Commentary

A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change.

Clifford SP, Mick PB, Derhake BM. Journal of investigative medicine high impact case reports. 2016;4:2324709616647746.

Transfusion errors can have serious consequences. This case analysis discusses a wrong-patient transfusion error in a hospital's emergency room and reviews findings of the subsequent root cause analysis, which determined training weaknesses, time pressures, and distractions within the team due to the chaotic nature of trauma care.