Patient identification errors in pre-transfusion blood sampling (‘wrong blood in tube’) are a persistent area of risk. These errors can potentially result in life-threatening complications. Current measures to address root causes of incidents and near misses have not resolved this problem and there is a need to look afresh at this issue. A narrative review of the literature was undertaken as part of a wider system-improvement project designed to explore and seek a better understanding of the factors that contribute to transfusion sampling error, as a prerequisite to examining current and potential approaches to error reduction. Two key themes emerged from the literature. Firstly, despite multi-faceted causes of error, the consistent element is the ever-present potential for human error. Secondly, current focus on error prevention could potentially be augmented with greater attention to error recovery. Exploring ways in which clinical staff taking samples might learn how to better identify their own errors is proposed to add to current safety initiatives.

Jane Oldham - Transfusion Practitioner, NHS Lothian and Member, Better Blood Transfusion team, NHS National Services Scotland