Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery.
Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. J Cardiothorac Surg. 2022;17(1):182. doi:10.1186/s13019-022-01931-6.
Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.