【正文】 ? Cryoprecipitate was issued on request, but was not used within 4 hours of thawing. It was taken out of the issue fridge the next day despite warnings from the electronic blood tracking system which were overridden by a BMS). The unit was then given to the patient. No adverse effects were noticed. insert your department, conference or presentation title ? Issue fridge not cleared over a weekend ? A patient had 3 units of red blood cells crossmatched and one of these units was transfused on day one. The remaining units stayed in the blood fridge ,No main issue fridge which was not cleared as it was a weekend. Over 72hours after the initial transfusion a second unit was taken from the blood fridge and transfused to the patient insert your department, conference or presentation title ? Leaking FFP bag fixed with sticky tape ? A 43 year old male patient was undergoing emergency laparotomy for internal bleeding. During administration of FFP, an operating department practitioner observed leakage from pack. The cause was unclear, possibly a faulty port or a spiked bag. He applied surgical 39。 B were in adjacent beds and both were crossmatched. Patient A (a 84 year old female patient, group A D negative) was prescribed 3 units of red cells for anaemia. Patient B (group AB D negative) was also crossmatched for 2 units of red cells, but the blood had not been prescribed. The registered nurse who went to collect blood for patient A took patient B?s blood in error. The unit was then taken to the ward when it was ?checked? by 2 trained nurses prior to being transfused but the error was not detected. The 15 minute observations were performed, but the patient did not display any signs or symptoms of a transfusion reaction. When the 1st unit was pleted it was fated via the puter system (EU Directive traceability). The next unit was collected, and the same error was repeated. Again the check by 2 qualified staff on the ward failed to detect the error and the second unit of Patient B?s blood was given to Patient A. For both units it was unclear what documentation was used in the collection process and where the final check occurred. The 15 minute observations were not performed for the second unit. The error was detected when the transfusion was plete. insert your department, conference or presentation title ? Well informed patient averts possible catastrophe ? No patient identification was taken to the blood fridge, as a result the wrong unit of red cells were removed by a registered nurse and taken to the ward for an 81 year old female patient with CLL. On the ward another nurse administering the transfusion assumed that the checks had been pleted, and because of this assumption no bedside checks were performed. Patient received non irradiated group A D positive red cells, instead of irradiated O D positive red cells. The error was noticed when patient asked whether the unit was irradiated. Consequently 50mls was transfused. insert your department, conference or presentation title ? Simultaneous transfusion of two patients leads to wrong unit being transfused ? Blood for two patients was delivered, in two separate blood transport boxes, to the nursing station by the porter, where the units were “checked”. One unit was taken out of each box and transfused to the appropriate patient. After the first patient, a 19 year old man with chronic renal failure and a post op Hb of g/dl, had received the first two units of blood, an unqualified B grade nurse went collected a third unit for him. However, she did not check that she picked up the correct unit from the blood box. She then put the unit up and menced the transfusion. A few minutes later, a qualified staff nurse responsible for the second patient went to get the second unit from the transport box and found the unit missing. It was then discovered that patient 1, group O D negative, was receiving the unit of blood intended for patient 2, group O D positive. insert your department, conference or presentation title ? Unit checked against crossmatch report rather than patient ? ITU staff nurse took the incorrect patient?s crossmatch report as identification to collect 2 units of red cells from the issue fridge. The units collected matched units on the report, and therefore were wrong for the intended patient. Once back at the ward the units were checked, again using the crossmatch report, and not the patient identification band. Thus 2 units of O D positive red cells were transfused to an O D negative male patient in error. insert your department, conference or presentation title Sampling / Results errors insert your department, conference or presentation title ? Bizarre results from Aamp。 her oxygen saturations were unrecordable. The nurse thought this was normal for the patient. The transfusion was pleted in one hour (not 6) and a fifth nurse then realised that the patient39。wasted39。E with a Hb of g/dl and gastrointestinal bleeding. Two units of blood were collected by a registered nurse from the issue fridge and menced via two cannulae. The patient became pyrexial with rigors, loin pain and hypotension and 1 hour after starting the transfusion the nurse called the doctor who stopped the transfusion: by this time most of both units was transfused. The doctor found that the red cell units were for a different patient, and that the units were inpatible, the patient being O D positive and the two transfused units B D negative. The patient received immediate supportive case and further advice was sought from the haematology consultant. A red cell exchange of 4 units of correct ABO/D group red cells took place. The patient suffered worsening renal impairment, and was later discharged to a hospice. insert your department, conference or presentation t