Bolton-Maggs Paula H B, Wood Erica M, Wiersum-Osselton Johanna C
Serious Hazards of Transfusion UK National Haemovigilance Scheme, Manchester Blood Centre and the University of Manchester, Manchester, UK.
Br J Haematol. 2015 Jan;168(1):3-13. doi: 10.1111/bjh.13137. Epub 2014 Oct 4.
'Wrong blood in tube' (WBIT) errors, where the blood in the tube is not that of the patient identified on the label, may lead to catastrophic outcomes, such as death from ABO-incompatible red cell transfusion. Transfusion is a multistep, multidisciplinary process in which the human error rate has remained unchanged despite multiple interventions (education, training, competency testing and guidelines). The most effective interventions are probably the introduction of end-to-end electronic systems and a group-check sample for patients about to receive their first transfusion, but neither of these eradicates all errors. Further longer term studies are required with assessment before and after introduction of the intervention. Although most focus has been on WBIT in relation to blood transfusion, all pathology samples should be identified and linked to the correct patient with the same degree of care. Human factors education and training could help to increase awareness of human vulnerability to error, particularly in the medical setting where there are many risk factors.
“试管内血液错误”（WBIT），即试管内的血液并非标签上所标识患者的血液，可能会导致灾难性后果，例如因ABO血型不相容的红细胞输血而死亡。输血是一个多步骤、多学科的过程，尽管采取了多种干预措施（教育、培训、能力测试和指南），人为错误率仍未改变。最有效的干预措施可能是引入端到端电子系统以及对即将接受首次输血的患者进行小组核对样本，但这两种措施都无法消除所有错误。需要在引入干预措施之前和之后进行评估的进一步长期研究。尽管大多数关注都集中在与输血相关的WBIT上，但所有病理样本都应以同样谨慎的态度进行识别并与正确的患者相关联。人为因素教育和培训有助于提高对人类易犯错误的认识，特别是在存在许多风险因素的医疗环境中。
