| Summary: | Introduction. The concept of blood safety includes the entire transfusion
chain starting with the collection of blood from the blood donor, and ending
with blood transfusion to the patient. The concept involves quality
management system as the systematic monitoring of adverse reactions and
incidents regarding the blood donor or patient. Monitoring of near-miss
errors show the critical points in the working process and increase
transfusion safety. Objective. The aim of the study was to present the
analysis results of adverse and unexpected events in transfusion practice
with a potential risk to the health of blood donors and patients. Methods.
One-year retrospective study was based on the collection, analysis and
interpretation of written reports on medical errors in the Blood Transfusion
Institute of Vojvodina. Results. Errors were distributed according to the
type, frequency and part of the working process where they occurred. Possible
causes and corrective actions were described for each error. The study showed
that there were not errors with potential health consequences for the blood
donor/patient. Errors with potentially damaging consequences for patients
were detected throughout the entire transfusion chain. Most of the errors
were identified in the preanalytical phase. The human factor was responsible
for the largest number of errors. Conclusion. Error reporting system has an
important role in the error management and the reduction of
transfusion-related risk of adverse events and incidents. The ongoing
analysis reveals the strengths and weaknesses of the entire process and
indicates the necessary changes. Errors in transfusion medicine can be
avoided in a large percentage and prevention is costeffective, systematic and
applicable.
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