• Commentary
  • Published May 2016

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

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.

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