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breaking cycle multiple errors resulting transfusion incorrect blood components julie ball1 hema mistry1 christine gallagher1 debbi poles1 paula h b bolton maggs1 2 1the shot office manchester blood centre 2university manchester uk behalf shot steering group bbts 26th september 2014 copyright shot reports analysed 2013 excluding miss right blood right patient n 184 n 996 2135 77 6 errors n 955 bbts 26th september 2014 copyright shot deaths serious harm associated error reports 2013 5 deaths dela

transfusion management haemostatic changes major obstetric haemorrhage uk green l1 knight m6 seeney fm2 collins pw3 collis re5 hopkinson cl2 stanworth sj4 health nhs trust nhs blood transplant london united kingdom 2statistics clinical studies nhs blood transplant bristol united kingdom 3arthur bloom haemophilia centre cardiff university cardiff united kingdom 4nhs blood transplant oxford university hospitals nhs trust oxford united kingdom 5dept anaesthetics cardiff vale university health board

the impact providing blood scene accident transfusion laboratory practice sonia wolf joan morris kim kennedy megan lawn terence mcloughlin kelly feane james uprichard anne weaver shubha allard laura green introduction trauma uk s leading cause death under 40s 25 die 6 hours haemorrhage accounts 40 trauma deaths 1 3 trauma patients a coagulopathy arriving hospital patients receive massive transfusions increased risk sepsis multi organ failure longer hospital stays commencing transfusion golden ho

the trouble trauma paul grist chief bms blood transfusion royal london 26th september 2014 bbts harrogate overview royal london hospital barts health nhs trust remote issue fridges remote issue fridges why 675 beds 110 wards departments 26 operating theatres purpose built laboratory 4th floor a building behind hospital remote issue fridges why remote issue fridges why 675 beds 110 wards departments 26 operating theatres purpose built laboratory 4th floor a building behind hospital eight remote i

pre operative assessment dr craig taylor andrea harris behalf wm rtc audit group a example audit cycle identify better blood transfusion 2002 2007 west midlands audit blood orthopaedic surgery 2005 transfusion rate v preop haemoglobin level primary hip surgery n 887 100 90 percentage patients transfused 80 70 60 50 40 30 20 10 0 8 10 10 12 12 14 14 16 preoperative hb g dl 16 postoperative perioperative uncertain timing west midland pre operative assessment clinics management anaemia survey 2005