The Serious Hazards of Transfusion haemovigilance scheme has documented adverse transfusion incidents for 22 years. Transmission of infection (three in 2018), transfusion-related lung injury (one in 2018) and transfusion-associated graft-versus-host disease (none since 2012) are rare. Despite national recommendations, guidelines and protocols, most incidents more than 85% of incidents are still due to errors in the transfusion process. European regulation and mandatory competency assessments have been associated with a reduction in ABO-incompatible transfusion, but errors continue to put patients at risk. What can be done? Errors are reduced by the use of electronic identification systems. Exploration of human factors and ergonomics (HFE) results in amended approaches away from blaming individuals to a full review of the systems and environment. Research examining how transfusion is performed (work-as-done) compared to work-as-imagined (set out in protocols and guidelines) discovers where variability results in either resilience or error. All staff require HFE training, but this should be alongside employment of suitably qualified and experienced HFE professionals. Good teamwork is key and is undermined by insufficient staffing and poor morale. The five choosing wisely recommendations for transfusion (to ensure appropriate use) need to be widely disseminated to medical staff in all specialties to ensure patients participate in the decision-making.

中文翻译：

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输血错误-可以消除吗？

输血严重危害血液警戒计划已记录了22年的不良输血事件。感染的传播（2018年为3例），输血相关的肺损伤（2018年为1例）和输血相关的移植物抗宿主病（2012年以来没有发生）。尽管有国家的建议，指南和协议，大多数事件中仍有超过85％的事件是由于输血过程中的错误造成的。欧洲法规和强制性能力评估与减少ABO不相容输血有关，但错误继续使患者处于危险之中。该怎么办？通过使用电子识别系统可以减少错误。对人为因素和人体工程学（HFE）的探索导致了从指责个人到对系统和环境进行全面审查的修改方法。研究人员对输血是如何进行（完成工作）与想象中的工作（协议和指南中所述）进行比较的研究发现，可变性在哪里导致弹性或错误。所有员工都需要HFE培训，但这应与雇用具有适当资格和经验的HFE专业人士一起进行。良好的团队合作是关键，人员不足和士气低落会破坏团队合作。需要将五种明智选择的输血建议（确保适当使用）广泛传播给各个专业的医务人员，以确保患者参与决策。但这应与雇用具有适当资格和经验的HFE专业人士一起进行。良好的团队合作是关键，人员不足和士气低落会破坏团队合作。需要将五种明智选择的输血建议（确保适当使用）广泛传播给各个专业的医务人员，以确保患者参与决策。但这应与雇用具有适当资格和经验的HFE专业人士一起进行。良好的团队合作是关键，人员不足和士气低落会破坏团队合作。需要将五种明智选择的输血建议（以确保适当使用）广泛传播给各个专业的医务人员，以确保患者参与决策。