Finding	Recommendation
Prelabelled cross match sample tubes are a source of misidentity	Current BCSH guideline recommends labelling at the bedside after the sample is drawn
Request for blood may omit special requirements, especially over the telephone	Request systems must ensure that all requirements are met and that responsibilities of ward and blood bank staff are clear
Previous transfusion information was not always used in decision making	Previous transfusion records should be available at all times and blood groups checked with current results
Blood bank errors in grouping, cross matching, and labelling were found	Blood banks should review procedures for adherence to national guidelines and ensure ongoing staff training
The most important primary cause of error was in collecting blood from the blood bank	Hospitals should review current procedures and define minimum identification requirements. Novel IT systems merit evaluation
Lack of patient wristbands or other identifiers was a source of wrong blood being transfused	Procedures to ensure correct patient identification are particularly important in theatre and for outpatient transfusions
Earlier errors are not being detected at the final bedside check, even if two qualified staff check the blood	BCSH will produce a national guideline to cover this issue; hospitals will be responsible for implementation and staff training
Local systems for staff training and oversight of transfusion practice are variable	Every hospital should have a transfusion committee with responsibility for all matters related to transfusions
Several organisations are responsible for decision making in transfusion safety	A unified approach to setting priorities for transfusion safety would ensure best use of resources
Investigation of transfusion reactions was variable and may have led to underestimation of bacterial transmission	Standardised protocols for joint investigation of suspected bacterial sepsis and immunological reactions between hospitals and blood centres would be helpful