Noticing errors in blood transfusion prevents harm to patients

Errors in blood transfusion can lead to serious patient harm, including death or major morbidity, especially as a result of ABO incompatibility. The transfusion process is a complex sociotechnical system and relies on multidisciplinary teams (MDT) of healthcare professionals, hence there are many opportunities for error. Serious Hazards of Transfusion (SHOT) is the United Kingdom (UK) independent, professionally-led haemovigilance scheme, which has collected and analysed anonymised information on adverse events and reactions in blood transfusion since 1996. The emphasis has been to learn from what goes wrong in these incidents, but the recent development of the safety II concept helped to see the importance of learning from what goes right. Investigation of near miss errors (what eventually goes right) can show where resilience/recovery within the transfusion process could be enhanced. Therefore, SHOT near miss incidents in calendar years 2014 and 2015 were analysed for how noticing actions prevented harm to patients, including what was noticed, by whom and what action they took. To do this, the near miss reports were searched for the words notice/noticed/noticing and various synonyms of these words. A total of 778/2410 (32.3%) near miss incident reports showed noticing actions had prevented patent harm. Of these, 552/778 (71.0%) were noticed by clinical staff and 226/778 (29.0%) by laboratory staff. Clinical staff performing the final ‘bedside check’ before administering the transfusion are the largest group to notice errors 327/552 (59.2%), showing the final check is crucial to patient safety. Noticing actions can prevent transfusion-related patient harm and demonstrate the value of situation awareness throughout the complex transfusion process