Linden J V
Blood and Tissue Resources Program, Wadsworth Center, New York State Department of Health, Albany.
Arch Pathol Lab Med. 1999 Jul;123(7):563-5. doi: 10.5858/1999-123-0563-EITM.
Error is ubiquitous whenever humans are involved in a process. Fortunately, most transfusion-related errors are benign. However, the risk of death due to acute hemolytic transfusion reaction rivals that of human immunodeficiency virus transmission and administration of the wrong blood or of blood to the wrong recipient has occurred at many facilities. Most blood misadministration errors are caused by failure to identify the recipient and blood unit adequately, although phlebotomy errors and blood bank errors also contribute. Many errors are multifactorial and may reflect underlying systems defects. Noncompliant specimen labels may be a cue to an increased risk of phlebotomy error. Autologous blood is not immune from error and poses infectious disease risks as well as the risk of hemolytic transfusion reaction; also, perioperatively recovered blood may pose a risk of air embolism if improperly handled.
只要有人类参与某个过程，错误就无处不在。幸运的是，大多数与输血相关的错误并无大碍。然而，急性溶血性输血反应导致死亡的风险与人类免疫缺陷病毒传播的风险相当，而且在许多医疗机构都发生过将错误的血液输给错误的受血者或把血液输给错误受血者的情况。大多数血液误用错误是由于未能充分识别受血者和血袋，不过静脉穿刺错误和血库错误也有一定影响。许多错误是多因素造成的，可能反映出潜在的系统缺陷。不符合规定的标本标签可能提示静脉穿刺错误风险增加。自体血也难免出错，存在传染病风险以及溶血性输血反应风险；此外，围手术期回收的血液如果处理不当可能会有空气栓塞风险。
