Blood transfusion sampling and a greater role for error recovery.

摘要: Introduction: Patient identification errors in pre-transfusion blood sampling (‘wrong tube’) are a persistent area of risk. These can potentially result life-threatening complications. Current measures to address root causes incidents and near misses have not resolved this problem there is need look afresh at issue. Project purpose: This narrative review the literature part wider system-improvement project designed explore seek better understanding factors that contribute transfusion error as prerequisite examining current potential approaches reduction. Search strategy: A broad search was undertaken identify themes relating phenomenon. Key discoveries: Two key emerged from literature. Firstly, despite multi-faceted error, consistent element ever-present for human error. Secondly, focus on prevention could be augmented...