Table 3.

Reported errors by category – number and rates

Error category	Subcategory	Number of reports	Rate of all errors, %
Avoidable, delayed or undertransfusion (no near misses)	Avoidable, discarded /wasted blood products	6	2.01
	Delayed	22	6.15
	Overtransfusion / TACO	9	3.02
	Undertransfusion	3	1.01
	Coagulation management and dosing error	20	6.71
Sum		60	18.6
Incorrect blood component transfused	Wrong kind of blood product transfused	8	2.68
For mismatches during actual administrations or near misses see table 4
	Unmatched	2	0.67
Wrong blood or recipient	Incompatible	6	2.01
Wrong blood or recipient	Compatible	30 (for details see table 4)	10.1
	Specific requirements for component not met	1	0.34
Sum		47	15.8
Errors related to preoperative donation or cell salvage	Use and production of autologous products	11	3.69
	Cell saver defect (technical)	1	0.34
	Mismatch of products following disconnection or confusion of autologous products	1	0.34
Sum		13	4.36
Patient identification (ID)	Screen and/or type test probe from wrong patient	9	3.02
	Laboratory test or bedside test from wrong patient	2	0.67
	Administration of blood /coagulation product	5	1.68
Sum		16	5.37
Handling and storage errors
Labeling	Labeling of blood samples/probes/ tubes	7	2.35
	Labeling of chart, blood order forms or other documents	2	0.67
	Labeling of blood products /coagulation products /drugs	5	1.68
Laboratory	Laboratory/POCT error including result output and pre-analytic errors	10	3.36
	Testing error	1	0.34
Storage	Storage errors	4	1.34
	Temperature deviation	3	1.01
	Component expiry	1	0.34
Product release	Unit booking-off from depot or blood bank	5	1.68
Transport	Transport error	1	0.34
Sum		39	13.1
Administration error
Indication	Indication for transfusion erroneous due to lab or preanalytic error, missing guideline coverage etc.	8	2.68
Blood management	Uncorrected preoperative anemia	1	0.34
	Transfusion trigger unrecognized	5	1.68
	Urgency of blood use	3	1.01
	Volume status assessment related to transfusion	6	2.01
Consent	Informed consent not done	1	0.34
Blood order	Blood order error (missed, incorrect, wrong patient, missing data)	5	1.68
Bedside test	Bedside test not done	1	0.34
	Bedside test wrongly interpreted / wrongly done	4	1.34
Preparation of transfusion procedure administration	Type and Screen, crossmatch	6	2.01
	Pretransfusion procedure	12	4.03
	Timing	5	1.68
	Delegation of transfusion	2	0.67
	Screening test result expiry	2	0.67
	Multiple transfusion processes for various patients synchronously or massive transfusion as contributing factor	9	3.02
	Double unit administration	3	1.01
Monitoring	Monitoring during administration	1	0.34
Documentation	Documentation of administration	1	0.34
Sum		75	25.2
Errors related to IT
	Wrong record selected	0	0
	Failure to consult or identify historical record	1	0.34
	Warning flag not updated or removed in error	0	0
	Computer or other IT systems failure	1	0.34
	Incorrect entry	2	0.67
	Electronic blood order	3	1.01
	Administrator/system related error	0	0
Sum		7	2.35
Errors related to analog documentation paper based forms/charts/documentation	Unreadable, wrong chart, etc.	4	1.34
Sum		4	1.34
Other equipment failure	Technical failure of used equipment	4	1.34
	Wrong use of equipment or no equipment	5	1.68
	Understaffing	3	1.01
Sum		12	4.03
Communication	Subject to subject (interindividually/interinstitutionally)	20	6.71
	Subject and technique including IT, laboratory and monitoring	5	1.68
Sum		25	8.39
Total sum		298	100

ID = Identity check; IT = information technology; KIS = hospital information system; POCT = point of care testing; TACO = transfusion associated circulatory overload.