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Wrong blood in tube (WBIT) errors can be classified as intended patient drawn/wrong label applied or wrong patient/intended label applied. In this international study, errors were divided almost evenly between the two types and most were a combination of protocol violations (e.g. technology not used or not used appropriately) and slips/lapses (e.g., registration errors). Additional contributory factors and recommendations for improvement are also discussed.

This analysis of transfusion-related safety incident reports found that such events were more commonly reported for pediatric compared to adult patients. This finding could reflect differences in reporting practices or underlying transfusion safety differences. The authors call for continued attention to transfusion safety.

Wrong-patient errors in blood transfusion can lead to serious patient harm. Research has shown that use of barcodes to ensure correct patient identification can reduce medication errors, but less is known about barcoding in transfusion management. This pre–post study examined the impact of barcode labeling on the rate of wrong blood in tube errors. Investigators found that use of barcoding improved the accuracy of labels on blood samples and samples that had even minor labeling errors had an increased chance of misidentifying the patient. The authors conclude that the results support the use of barcoding and the exclusion of blood samples with even minor labeling errors in order to ensure safe blood transfusion. An accompanying editorial delineates the complex workflow, hardware, and software required to implement barcoding for transfusion. A past WebM&M commentary discussed an incident involving a mislabeled blood specimen.

Transfusion of incompatible blood products can cause severe patient harm and is considered a never event. Based on findings in this study, researchers suggest that use of a blood product compatibility cognitive aid may improve transfusion safety.

Failure mode and effect analysis (FMEA) is a tool that facilitates prospective risk assessment and is frequently used to assess the risk of various processes in health care. The authors describe the use of FMEA at a single institution to improve the safety of the blood transfusion process.

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.

Mistakes during blood transfusion can contribute to patient harm. This review discusses the use of health information technology, such as computerized provider order entry and clinical decision support systems, in transfusion medicine to enhance reliability of ordering practices and enable monitoring of adherence.

Data from root cause analyses were used to identify causal factors for patient misidentification errors in clinical laboratories, pathology, and the blood bank.

This article describes the process used to detect mismatched umbilical cord blood prior to transplantation. Failure to detect the mismatches would have led to devastating clinical consequences.

This simulation study examined the effect of distractions on anesthesiologists' performance of measures to ensure blood transfusion safety.

The physician author recounts the story of her father's death—a death that she feels was preventable and caused, in part, by errors in judgment made during his care.

The author discusses three transfusion case studies that highlight three areas where errors are most common and technologies that can be used to prevent errors in these areas.