Human error—a significant cause of transfusion mortality

Volume 40, July 2000 TRANSFUSION 879 Errors have occurred in blood transfusions since the technique began to be used. In 1972, FDA assumed inspection and licensing control over the various groups involved in transfusion medicine. One requirement was the mandatory reporting of all fatalities linked to blood transfusion and donation. Periodic reviews of these reports by various authors have shown one of the major causes of fatalities is clerical errors during the administration of blood and in the laboratory. Although corrective measures were made, little thought appears to have been given to two principles: that humans will inevitably make errors, and that the system design must be such that it decreases errors and detects residual errors that evade corrective procedures. An organized and standardized report of these errors is not available to study mistakes and what can be done about them. This type of analysis is available in the aircraft industry and has contributed greatly to improving the safety of flying. A plea is made for the institution of a nonpartisan data-collection agency to which fatalities and anonymous error reports could be sent, and which would analyze and publish these data on a periodic basis for the benefit of manufacturers, transfusion services, and the general public. BACKGROUND