Wrong blood/wrong patient

Definition

Where a patient is transfused with a blood component of an incorrect blood group, or which was intended for another patient.

This could potentially lead to an ABO incompatible transfusion, which could be fatal.

Frequency

Very rare (<1 in 10,000) as a result of safety checks at all stages in the transfusion process.

Reducing the risk

All staff involved in transfusion should be appropriately trained.

They will undertake essential patient identification checks at each stage of the transfusion process, including when taking a blood sample, and at authorisation, collection and administration.

Staff will only be involved in one transfusion at a time.

The patient should expect to be asked their full name and date of birth at the least, and has a right to ask if this does not happen.

Safety checks built into laboratory IT systems ensure the patient’s current sample is consistent with their previous blood group results and help prevent an incorrect unit being issued.

Further information and resources

Serious Hazards of Transfusion (SHOT) educational resources:

• SHOT Safe transfusion practice - Transfusion checklist
• SHOT ABO incompatible transfusion events - 2010-2019