【正文】 s medical notes. The FFP was nevertheless transfused inappropriately 9 hours later despite normal coagulation screen and no evidence of active bleeding. insert your department, conference or presentation title ? White cell count mistaken for Hb resulting in unnecessary transfusion ? A 70 year old woman presented in A/E looking very pale and had fainted at home. Full blood count run on a POCT analyser in Aamp。S to cover a possible bleed but the patient was not to be transfused until further results were available. The junior doctor was confused between a crossmatch and group and save” request. insert your department, conference or presentation title ? Disagreement about necessity of prophylactic platelets ? A 47 year old man with ALL was booked for insertion of a Hickman line. Platelet cover was on standby and the Consultant Haematologist instructed that platelets were not to be given if the count was 50 x 109/l. The platelet count was 57 x 109/l, but the radiologist would not insert the Hickman line without platelets being transfused prior to procedure. The patient was returned to ward where the SHO prescribed the platelets against consultants advice and outside of national guidelines. The patient returned to XRay where the line was inserted. insert your department, conference or presentation title ? Emergency blood given in haste by a junior doctor ? A 28 year old man required a repair to an arterial laceration in the anticubital fossa. Surgical HO demanded 2 units of 0 negative emergency blood. In fact the patient?s group was known and 4 units had been crossmatched and were already available in the same refrigerator. insert your department, conference or presentation title ? Involvement of too many personnel in decision to transfuse ? A 20 month old girl on regular dialysis for end stage renal failure attended for routine haemodialysis and her father reported that she had been unwell. A consultant menced dialysis urgently and as the Hb was g/dl requested 2 units of blood to be given during dialysis. The dialysis was pleted before the blood was ready so a decision was made by a second consultant to give 250ml of blood slowly over 6 hours. This message was conveyed between the dialysis unit nurse and the ward nurse by the patient?s father. The notes were later collected and a third and fourth nurse set up the transfusion. Observations were done by the fourth nurse. No pretransfusion observations were done. At 5, 20 and 35 minutes into the transfusion the patient was hypertensive, tachypnoeic and irritable。wasted39。 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. Onc