Annual SHOT Report 2016

Abstract

ABO-incompatible transfusions are the tip of the iceberg; they most commonly result from failure to identify the patient at the time of blood sampling (wrong blood in tube) or administration to the wrong patient. Pulmonary complications, particularly transfusion-associated circulatory overload (TACO), cause the most deaths and major morbidity. Delayed transfusions are an important cause of death, 25/115 (21.7%) 2010 to 2016. Many errors in transfusion, some with serious clinical consequences, relate to poor communication between teams, shifts and interfaces. The infrastructure needs improvement to facilitate exchange of results within and between hospitals. IT errors contributed to 1 in 5 SAE reported. IT is not infallible, it makes transfusion practice safer by helping to control and support the task, but does not replace knowledge about the task.