The process for delivering blood transfusions needs to be redesigned to reduce mistakes, a new report has recommended, after an audit found human error was the most common cause of patient harm.
The annual Serious Hazards of Transfusion (SHOT) report analysed details of more than 2,700 UK transfusions where patients were harmed or almost harmed during 2013.
It found human factors, such as poor communication, were responsible for more than three quarters of reports to the audit. The report found many transfusion errors had been preceded by a number of errors from the lab to the bedside.
The audit found the most frequent result of error was the transfusion of the wrong blood component, which has potentially life threatening implications.
The report noted that the overall risk of transfusion in the UK is small, with a risk of death of eight per one million components issued. However, its authors are calling for a redesign of the process to design out errors, including the introduction of a five point bedside checklist.
SHOT medical director Dr Paula Bolton-Maggs said: “Mistakes frequently arise due to poor communication between clinical areas and the lab, and between different hospitals, departments within hospitals and between shifts. Mistakes also occur when staff omit essential identification checks.
“We need to make sure the right checks are made, right from the request for blood from the lab to it appearing at the patients’ bedside… A simple 5 point checklist completed at the patient’s side immediately prior to transfusion would catch many of the errors.”
Rebecca Gerrard from the patient blood management team at NHS Blood and Transplant, who are responsible for leading regional and national initiatives aimed at promoting safe and appropriate transfusion practice in England and North Wales said:
“We welcome the report’s recommendations. The SHOT UK haemovigilance scheme is hugely important as it helps provide the bigger picture across the NHS. This kind of monitoring and surveillance is vital to identifying trends in practice and demonstrating where there is room for improvement.
“Although the UK has one of the safest blood supply chains in the world, we should never be complacent and should always be looking to ensure the safest and highest quality transfusion practices.”