Preventing Mistransfusions: An Evaluation of Institutional Knowledge and a Response

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(Anesth Analg. 2018;126:247–251)The risk of transfusion of the wrong blood to the wrong patient is 3 times higher than the risk of infectious disease transmission through blood products. In the present study, the authors reported on their experience with a transfusion event, in which a patient with type AB blood type was given type A plasma with no negative sequelae. Following the analysis of the knowledge gap that occurred between the technician and the members of the anesthesia team, the authors evaluated the application of a point of care cognitive aid to bridge potentially lethal knowledge gaps among practitioners in blood product to patient compatibility.

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