A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet

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A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change.

June 15, 2016

Clifford SP, Mick PB, Derhake BM. J Investig Med High Impact Case Rep. 2016;4(2):2324709616647746.

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Transfusion errors can have serious consequences. This case analysis discusses a wrong-patient transfusion error in a hospital's emergency room and reviews findings of the subsequent root cause analysis, which determined training weaknesses, time pressures, and distractions within the team due to the chaotic nature of trauma care.

PubMed citation

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Emergency Departments

Health Care Executives and Administrators

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Emergency Medicine

Transfusion Complications

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