Blood transfusions are necessary, but can be a life threatening event, therefore they are continuously monitored and evaluated by both the hospitals themselves, as well as many accreditation organizations. Studies that look at medical errors show that blood transfusions are one of the most common high risk procedures and are categorized as critical medical errors due to the high risk of morbidity and mortality (Najafpour et al., 2017). Errors related to blood transfusions tend to occur because of some external force, whether it be cognitive, human traits, or organizational or human factors. (Brown & Brown, 2023). Nurses may have the knowledge and understanding, however the environment usually contributes to the likelihood of errors. If there is a trend noted, it is doubtful to be an individual failure, but more a issue in the system that is failing the individuals.

The potential for error can occur in every step of a blood transfusion, including patient identification, blood typing, cross-matching, and other human errors. There are various methods that can be used to address these errors including Plan-Do-Study-Act (PDSA), Lean Methodology, Six Sigma, Failure Modes and Effects Analysis (FEMA) or a Root Cause Analysis (RCA). Due to the high risk nature of blood administration errors, I feel that FEMA is the best tool because it is a proactive tool to help identify potential failure points in the administration process before they could occur. By using FEMA you can help predict and mitigate the risk of these errors (Brown & Brown, 2023).

Brown, C., & Brown, M. (2023). Blood and blood products transfusion errors: what can we do to improve patient safety? British Journal of Nursing, 32(7), 326–332. https://doi.org/10.12968/bjon.2023.32.7.326

Najafpour, Z., Hasoumi, M., Behzadi, F., Mohamadi, E., Jafary, M., & Saeedi, M. (2017). Preventing blood transfusion failures: FMEA, an effective assessment method. BMC Health Services Research, 17(1). https://doi.org/10.1186/s12913-017-2380-3