Blood and blood products transfusion errors: what can we do to improve patient safety?

Abstract

Evidence suggests that blood transfusion errors tend to occur because of an external stimulus, limiting control for the professional administering it. Whether it be cognitive bias, human traits, organisational or human factors, errors should be prevented because they put the safety of the patient at risk from major morbidity and mortality. The authors explored the literature that looked at the blood transfusion errors that occur, suggesting interventions that may have a positive impact on patient safety. A review of the literature was undertaken using key words and limiters to focus the search. The review found that, when practitioners do not perform skills or interventions regularly, competence diminishes. Training and rolling refresher programmes appeared to improve retention and knowledge, therefore enhancing patient safety. Consequently, the impact of human factors in the healthcare setting requires more comprehensive investigation. Nurses may have the knowledge and understanding regarding blood transfusions; however, the environment in which they work could contribute to the likelihood of errors.

Keywords: Blood transfusion; Blood transfusion errors; Nurse errors; Patient safety.