[Transfusional accident by successive mistakes (author's transl)].

A blood unit is transfused to a female patient, urgently. The names written on the form and on the vial are not identical. The determination of blood group is made by one person, instead of two, because the second one has been affected to a new hospital which is opening its doors. The only name of the vial is read. That is two mistakes. Thirdly, the blood grouping of the patient had already been realized, but is not looked for. Fourthly, the anaesthetist makes a wrong verification in the operating room. On the wrong blood unit was written the right name of the patient. No clinical symptoms appears during the intervention, on by oliguria 7 hours later. Haemodialysis. 13 days later the patient goes out in good health.