Root causes of blood transfusion errors:

 Lab near miss:

- In correct interpretation of ABO and Rhesus blood grouping.
- In correct specimen handling because of the laboratory technologists were
distracted when handling samples.
- Frequent phone calls made by the wards to confirm cross matching results.
- Urgent requests call from clinicians and pressure from clinicians to release blood
early.
- • Policy on collecting and labeling type/screen not followed
- • Sample not labeled with the patient info at time of collection
- • Two nurses did not verify sample at bedside
- • Type/screen and ABO/Rh compatibility performed together
- • Type/screen label format varies based on the printer location

- People:
health care providers According to the International Ergonomics Society, ergonomics or
(the more commonly known) human factors can be defined as: ‘...a scientific discipline
concerned with the understanding of interactions among humans and other elements of a
system, and the profession that applies theory, principles, data and methods to design in
order to optimise human well-being and overall system performance’ (International
Ergonomics Association 2000).

- Put simply, HF deals with factors influencing human performance, such as physical
environments, individual characteristics, and management systems. It can contribute
to describing known WBIT errors and discovering unidentified ones, as well as
expanding our understanding of their underlying causal factors. HF is necessary in the
investigation of errors surrounding mislabelling and miscollection of blood samples
since, in spite of attempts to reduce WBITs
- Most of blood taking is performed by junior doctors.
- Age of the doctors: older ages decrease the odds of having a near miss events.
- Poor communication, taking of blood sample not documented in notes by any
member on duty at night.
- misunderstanding between nursing staff.
- Multitasking nurses staff and no defined roles for each nurse.
- High work load.
- Shortage of nursing staff and inadequate training.
- In adequate patient identification is recognized as a root causes for serious
transfusion errors (Murphy and Kay 2004), include in correct ID band or wrist
band or chart of the patient.
- Failure to check patient identity due to similar names of patients.
 - Education and training: Majority of emergency department staff have not
received blood training, due to busy workload.

 Blood samples:
- Wrong blood samples in tube : received the wrong blood type regarding platelet,
red blood cell and plasma.
- ‘Wrong Blood in Tube’ (WBIT) errors are those that occur where patient identification
information (label and request form) belong to one patient but the blood in the tube
belongs to another patient (Dzik, Corwin et al. 2003). WBIT errors most commonly occur
at blood sample collection and are estimated to affect approximately 1 in 2000 samples
(Gonzalez-Porras, Graciani et al. 2008). Mislabelling tubes occurs more often, affecting,
on average, 1 in 40 samples (Murphy and Kay 2004). The most severe result of WBIT is a
patient receiving a transfusion of the wrong type of blood (incompatible blood
component transfused - IBCT) which can result in death. Therefore, in spite of their low
frequency, WBITs can have catastrophic consequences. ‘Silent WBITs’, which occur
when a patient is transfused, by chance, with blood of a matching type to their own in
spite of a WBIT error at sample collection, remain hidden in the system. Rates of silent
WBITs are unknown
- Delayed orders and not followed.
- No cross match completed before blood given to patients.
- Blood sample is not tested for diseases ( contaminated blood )
 Blood orders :
- • Massive blood transfusion (MBT) is a low-frequency, high-risk
- event with unclear accessibility to decision making support
- • No process for ordering blood or resource organization for
- off-tour hours
- • No standard communication process for staff and leadership
- support
 method:
- this is an area where practice may be less than ideal. Staff are often assumed to have
had adequate training although taught at different levels, by different teachers and with
varied methodologies and without ongoing performance assessment. They undertake
phlebotomy with limited supervision, and are often resistant to changing their
technique. These factors, combined with the various practices listed above, make it easy
to understand how errors can occur. The nature of these errors makes HF a critical
research avenue. There are a number of HF issues linked with WBITs (Dzik 2003), such
as: • poor communication between staff • complexity of care and urgency of tasks •
confusing product labelling or packaging • incomplete or inadequate education •
insufficient staffing or patient monitoring, and • lack of automation or technologies that
are mismatched to work processes
- lack of modern and standard procedures.
- lack of proper verification before transfusion.
 - Inaccurate verbal instructions, no request forms of blood transfusions.
- Inadequate documentation of near miss reporting.
- Mislabeling occurred due to taking blood samples from different patients at the
same time.
- Samples was labeled away from the location of blood taking cause wrong blood
in tube incidents.
- Education and training: Majority of emergency department staff have not
received blood training, due to busy workload.
- Limited access to policies related to blood transfusion processes
- Lack of informed consent and consent not noted in patient chart as required
before blood transfusion.
- The lack of a medical center memorandum noting blood component can be infused up
to four hours
- Low-frequency task

 Working condition and environment:

- Busy night shift is causing pressure on working place.
- Multitasking
 Patient Identification:
- incorrect ID labels, wristband, chart, etc.; lack of proper verification
before transfusion