【正文】 e 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。 tape to the pack to prevent further leakage, and the transfusion continued. insert your department, conference or presentation title ? Erroneous use of solution giving set ? An experienced agency nurse used a normal solution giving set instead of a blood giving set with an inline filter for transfusion of packed red cells insert your department, conference or presentation title ? Expired red cells transfused ? Patient received approx 100 mls of expired red cells. 2 units of blood were issued in response to a request for urgent crossmatch for an anaemic 87 year old female patient. One of the units was due to expire that day at midnight. I。E using a syringe during a difficult cannulation. The red cells may have settled in the syringe before the sample tubes were filled, giving an inaccurate result. No IV fluids were in progress at the time. This doctor prescribed 2 units of red cells. The patient was referred to a medical team and another junior doctor prescribed a further 2 units of red cells making a total of 4 units. No adverse reaction or ill effects were noted from the transfusion. insert your department, conference or presentation title ? A case of TACO after use of FFP to reverse warfarinisation ? A 61yearold male patient with an INR of required warfarin reversal prior to elective surgery. He was given Vitamin K 5 mg and four bags of FFP over 160 minutes. Without any further INR being performed he then received another three bags over 45 minutes, at which point he became unwell with rigors, chills, wheeze and a temperature of . His oxygen saturation on air was 80%. He was managed with diuretics and oxygen. The planned surgery was performed the following day. insert your department, conference or presentation title ? Excessive transfusion follows misinterpretation of verbal instructions ? A 48 year old male patient was in resus with a major GI bleed haemorrhage. Five units of blood arrived and a verbal order for 2 units was given by the doctor, who then wrote them up on a prescription chart. Staff nurse asked the doctor if he wanted the blood given through the rapid transfuser, and he confirmed that ?all the blood can go though this?. Five units were transfused instead of the intended 2 units. insert your department, conference or presentation title ? Excess red cells are administered to an infant despite correct dose calculation and prescription ? 171 ml of red cells were transfused over 7 hours to a 3 month old baby with a rhabdomyosara. The child had only been prescribed 80ml over 3 hours, and her Hb consequently rose from to g/dl. The error was partly caused by a failure to include the 71 ml given during the night shift to the volume given during the morning. However the day staff still transfused yet another additional 20 ml for which no rationalization could be made. insert your department, conference or presentation title ? Helpful nurses and doctor administer platelets to the wrong patient ? Platelets arrived in ITU and sister took them a patient?s bedside. This was not the bedside of the patient to be administered platelets. However, finding the patient unconscious and without an ID bracelet she went to write a wristband. Two other nurses saw the platelets and checked them by asking other staff if it was the correct patient. Finding the platelets were not written up for that patient, they asked the doctor to prescribe them, which he did. The platelets were then given to this patient who did not require them, but they were for another patient on the unit. There was no adverse reaction. insert your department, conference or presentation title ? Confusion regarding ponents results in unwanted red cell transfusion and delayed surgery ? A 77 year old man had prophylactic platelets written up prior to spinal depression surgery. Night nurses erroneously collected red cells which were also available for the same patient as they were cross matched for the morning list. Two units of red cells were transfused over 30 minutes each, and no platelets. In the nursing notes the transfusions were documented as platelets, and it seemed that the staff were unfamiliar with the different types of blood ponent. The surgery had to be delayed in the morning when the day staff discovered the error. insert your department, conference or presentation title ? Lack of understanding of possible consequences of actions ? 2 trained nurses checked a unit of blood at the nurse?s station and a nurse then walked into a 6 bedded bay and connected it to the wrong patient with no bedside check. The nurse then realised her mistake, disconnected the giving set from the wrong patient and reconnected it directly to the right patient. A senior colleague queries her actions as she had used a fluid giving set, not a blood giving set. The nurse was sent away and the senior nurse changed the giving set as she was unaware of the previous mistake. The rest of the transfusion was then administered (to the right patient). The patient who had received a part unit of wrong blood was not monitored and nothing was documented in the notes. insert your department, conference or presentation title ? Size of patient not taken into account when prescribing red cells ? An 18 year old male patient weighing 35kg, with a probable TB chest infection, received a 4 unit red cell transfusion based on an Hb result of referred