This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (7) Citing Articles via Google Scholar Google Scholar Articles by Krombach, J. Articles by Kasper, S.-M. Search for Related Content PubMed PubMed Citation Articles by Krombach, J. Articles by Kasper, S.-M. Related Collections Economics and Health Care Research Blood

---

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.

This article has been cited by other articles:

				T. Strong Vital Publics of Pure Blood Body Society, June 1, 2009; 15(2): 169 - 191. [Abstract] [PDF]

				B. G. Solheim Universal pathogen-reduced plasma in elective open-heart surgery and liver resection. Clin. Med. Res., September 1, 2006; 4(3): 209 - 217. [Abstract] [Full Text] [PDF]

				A. Shander, D. Moskowitz, and T. S. Rijhwani The Safety and Efficacy of "Bloodless" Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2005; 9(1): 53 - 63. [Abstract] [PDF]

				C. Marcucci, C. Madjdpour, and D. R. Spahn Allogeneic blood transfusions: benefit, risks and clinical indications in countries with a low or high human development index Br. Med. Bull., August 31, 2004; 70(1): 15 - 28. [Abstract] [Full Text] [PDF]

				F. Regan and C. Taylor Recent developments: Blood transfusion medicine BMJ, July 20, 2002; 325(7356): 143 - 147. [Full Text] [PDF]