Table 1.

Process steps covered by the reporting form

Form	Category description	Step
1) Blood product order	Each incident that happens before, after, while ordering a blood product from the blood bank or depot including the assessment of the need of transfusion	a) Identification of the patient by entry in the hospital's PDMS during the admittance in administration, ICU or emergency unit Assessment of the need of transfusion in a clinical situation of an individual by clinical situations, symptoms, laboratory and history b) Order of the right number of units or products by delegation, by filling an electronic or analog order form for this patient c) Organization of process initiation by defining time, dose, clinical situation and urgency, responsibility
2) Blood group sample withdrawal and tube labeling	Each incident that happens before, after, while blood withdrawal for type and screen, labeling and sending to the immunology laboratory	a) Preparation of blood containers, printing and labeling for the right individual b) Identification of the right patient for the blood withdrawal Blood withdrawal off the right patient in correct labeled containers at the right time
3) Laboratory handling of blood probes and products	Each incident that happens before during and after blood probe arrival, screen and type, release of ordered blood for all incidents in the laboratory, blood bank and depot from arrival to release of a compatible product	Errors of blood probe reception a) Acceptance of blood probes without correct labeling, in wrong tubes, insufficient volume, outdated since leaving the patient b) Mismatch at reception of blood probes for type and screen, confusion of attached documents Errors of blood group test either in an analyzer, gel cards, elution or other methods including c) Wrong results, no results despite antibody detectable, wrong diagnostic tool such as choose of wrong antibody panel, d) Delays in working on emergency cases associated with analysis, result reading, further diagnostic, and result output Errors associated to release of blood products while e) Retrieval of correct tested blood unit from storage f) Product checking out g) Releasing documentation and signature to the authorized person
4) Transport and handling of blood products	Each incident that happens on and with transport of probe from patient to laboratory, from probe transport to analyzer, blood product transport and storage within the blood depot, blood product transport from blood depot to the sub-depot or to the patient	a) Incorrect transport conditions i.e. temperature, box, contamination, not approved storage condition, etc. b) Avoidable delays of urgent deliveries c) Mix-up and confusion of several products for various recipients d) Damage to or loss of products e) Inadequate handling of probe during transport and waiting period for application, i.e. no agitation and extended storage of platelets
5) Blood product administration	Each incident that happens prior to product application to the recipient	a) Bedside test not done, wrong done, wrong interpreted, done from the wrong patient b) Mismatch of blood group documents of patients, blood group information on blood product and BST c) Inadequate preparation of products and transfusion sets, i.e. incomplete thawing, incomplete visual control of red cells for hemolysis d) Inadequate application condition, illegal delegation, inadequate venous access, wrong application mode or period, etc. e) Flawless documentation of application process f) No or insufficient monitoring during transfusion g) Any other administration error
6) Patient identification	Each incident that happens while receiving, documenting, matching the identity of patients, blood products or probes	a) Wrong patient ID at hospital admission due to mix-up, wrong ID given, wrong or no wrist band, unconsciousness and later misallocation of emergency number to ID b) Wrong identification procedure prior to withdrawal of blood probe or application of blood product
7) Others such as coagulation management, autologous processing or donation	Each incident that occurs in hemotherapy but does not fit the above classification within the process chain	a) Problems with or during production of autologous products by cell salvage and preoperative donation b) Problems with coagulation management, i.e. incorrect diagnostics, choosing the incorrect antidote or insufficient dosage, overdose, etc. c) Any other error not covered by any previous entry form

PDMS = Patient data management system; ICU = intensive care unit; ID = identity.