• Priti Elhence, S Veena, Raj Kumar Sharma, and R K Chaudhary.
• Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. pelhence@sgpgi.ac.in
• Transfusion. 2010 Dec 1;50(12 Pt 2):2772-7.

BackgroundAs part of ongoing efforts to improve transfusion safety, an error reporting system was implemented in our hospital-based transfusion medicine unit at a tertiary care medical institute. This system is based on Medical Event Reporting System-Transfusion Medicine (MERS-TM) and collects data on all near miss, no harm, and misadventures related to the transfusion process. Root cause analyses of one such innocuous appearing error demonstrate how weaknesses in the system can be identified to make necessary changes to achieve transfusion safety.Study Design And MethodsThe reported error was investigated, classified, coded, and analyzed using MERS-TM prototype, modified and adopted for our institute.ResultsThe consequent error was a "mistransfusion" but a "no-harm event" as the transfused unit was of the same blood group as the patient. It was a high event severity level error (level 1). Multiple errors preceded the final error at various functional locations in the transfusion process. Human, organizational, and patient-related factors were identified as root causes and corrective actions were initiated to prevent future occurrences.ConclusionThis case illustrates the usefulness of having an error reporting system in hospitals to highlight human and system failures associated with transfusion that may otherwise go unnoticed. Areas can be identified where resources need to be targeted to improve patient safety.© 2010 American Association of Blood Banks.

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