Table 4. Errors in the Clinical Stage of
Blood Transfusion, July 2008 through
July 2009
ERRORS
Reaction (e.g., fever, rigors,
tachycardia, hypotension,
chest pain, headache,
urticaria, dyspnea)
Intravenous line issues
(e.g., infiltration, leaking, no
filter, timing of greater than
four hours)
Wrong blood component
administered
Expired/wasted blood
component
No type and cross before
receiving blood component
(e.g., trauma, emergency
department)
Incomplete documentation
(e.g., unit tag saturated,
numbers obscured tag
numbers, no identification
numbers)
Identification band issues
(e.g., no blood bank band,
blood bank identification
number cut off, improperly
labeled blood bank band)
Wrong patient received blood
component
Order to type and hold only
but was mistakenly transfused
NUMBER OF
OCCURRENCES
(n = 111)
40
19
14
9
8
7
6
5
PATIENT
HARM
(n = 10)
4
2
3
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