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ECONOMICS AND HEALTH SYSTEMS RESEARCH

Human Error: The Persisting Risk of Blood Transfusion: A Report of Five Cases

Jens Krombach, MD^*, Sandra Kampe, MD^*, Birgit S. Gathof, MD, Christoph Diefenbach, MD^*, and Stefan-Mario Kasper, MD^*

*Department of Anesthesiology, Department of Transfusion Medicine and Blood BankUniversity of Cologne, Germany

Address correspondence and reprint requests to Jens Krombach, MD, Department of Anesthesiology, University of Cologne, 50924 Cologne, Germany. Address e-mail to krombach{at}netcologne.de

It is common experience that virus transmission, particularly transmission of the human immunodeficiency virus (HIV), is a principal concern of patients and physicians regarding blood transfusion (1). Many physicians are probably unaware that transfusion-transmitted HIV infection is approximately 50 to 100 times less likely to occur than transfusion error (2–4). This misconception may have been encouraged by the scarcity of reports on transfusion error relative to the tremendous public attention focused on HIV infection. We present five cases illustrating how anesthesiologists, intensivists, and emergency physicians are particularly vulnerable to the risk of administering blood to the wrong recipient. All five cases were collected during a 4-yr period. Transfused units of packed red cells totaled approximately 50,000 U during this period in our department.

IMPLICATIONS: Human error leading to the transfusion of blood to an unintended recipient is a major source of transfusion-related fatalities. We report five cases that highlight some specific areas in which transfusion error is likely to occur.

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999