Definition
Where a patient is transfused with a blood component of an incorrect blood group, or which was intended for another patient.
This could potentially lead to an ABO incompatible transfusion, which could be fatal.
Frequency
Very Rare (< 1/10,000) as a result of safety checks at all stages in the transfusion process.
Reducing the risk
All staff involved in transfusion must be appropriately trained
- they will undertake essential patient identification checks at each stage of the transfusion process:
> this includes taking a blood sample, authorisation, collection and administration
- they will only be involved in one transfusion at a time.
The patient should be asked their full name and date of birth at the least, and has a right to ask if this does not happen.
Safety checks built into laboratory IT systems ensure the patient’s current sample is consistent with their previous blood group results and this helps prevent an incorrect unit being issued.
Further information/ resources
SHOT Incorrect Blood Component Transfused (IBCT) Cumulative Data
SHOT Safe transfusion practice: Transfusion checklist
SHOT ABO-incompatible transfusion events 2010-2019 [video]
BSH Administration of Blood Components guideline (2017)