Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses


  • Elizabeth A. Lancaster, MHA Lexington Veterans Affairs Health Care System
  • Elizabeth K. Rhodus, PhD, OTR/L Lexington Veterans Affairs Health Care System, University of Kentucky Sanders-Brown Center on Aging
  • Mary B. Duke, MD Lexington Veterans Affairs Health Care System
  • Andrew M. Harris, MD Lexington Veterans Affairs Health Care System



blood transfusion - visual abstract

Blood transfusions are lifesaving treatments which require critical attention to processes and details. If processes are not followed, grievous errors can lead to sentinel events. A review of investigations completed due to reported events will show the error trends associated with systems used throughout the blood transfusion process.

This study employed root cause analyses (RCAs) within the Veterans Health Administration (VHA) to review the events leading to blood transfusion errors. Data was pulled from the RCA databases within the VA National Center for Patient Safety. The time frame was October 2014 to August 2019. A total of 53 RCAs and aggregated reviews were included in the study. These were reviewed for common themes and gaps present within processes.

The most common events fell within the categories of incorrect or delayed blood orders, incorrect or lack of patient identification, and wrong blood given. The RCA for each event was reviewed and studied. The RCAs had a crossover of multiple causes; lack of a formal process, communication barriers, and technology barriers were the most frequent.

These RCAs express great variation between VHA facilities, such as process created, number of staff reports, and number of RCAs completed. Lack of standard practices nationwide, training barriers, and technology barriers may explain the variation of transfusion errors throughout the VHA. This study brings to light questions about standardization of transfusion protocols. Future study regarding such standardization is necessary to determine its plausibility.

Author Biographies

Elizabeth A. Lancaster, MHA, Lexington Veterans Affairs Health Care System

Elizabeth A. Lancaster ( is a program support assistant within the Department of Quality, Performance, and Patient Safety at the Lexington VA Health Care System. She works closely with Patient Safety, Systems Redesign, and Risk Management to improve the safety and quality of care for veterans. She is also a program assistant and mentor for the Interprofessional Fellowship Program in Patient Safety, working in conjunction with the Lexington staff and the Veterans Affairs National Center for Patient Safety (NCPS). Prior to her new roles, she herself was a Patient Safety Fellow. She continues to be interested in using Lean and High Reliability Organization (HRO) principles to strengthen the VA Health Care System. Through the Fellowship, Lancaster became a Certified Professional in Patient Safety (CPPS).

Elizabeth K. Rhodus, PhD, OTR/L, Lexington Veterans Affairs Health Care System, University of Kentucky Sanders-Brown Center on Aging

Elizabeth K. Rhodus is a researcher at the University of Kentucky Sanders-Brown Center on Aging focused on translational research in Alzheimer’s disease. Dr. Rhodus has worked in healthcare and rehabilitation management as an occupational therapist with specialization in dementia care provision and care partner training. She also participated in the Advanced Fellowship in Patient Safety with the Veterans Affairs National Center for Patient Safety (NCPS), during which she received additional certification in Lean principles. Dr. Rhodus’ work is aimed to improve healthcare intervention options for older adults.

Mary B. Duke, MD, Lexington Veterans Affairs Health Care System

Mary B. Duke is the chief of medicine at the Lexington VA Health Care System. She has assisted and mentored the fellows within the Lexington VA Interprofessional Fellowship Program in Patient Safety since it began in 2007. Dr. Duke’s career has focused on medical education at the VA and the affiliated University of Kentucky College of Medicine. Previously, she served as associate chief of staff for education at the Lexington VA and as director for the internal medicine and pediatrics residency program at the UK College of Medicine, where she is an associate professor.

Andrew M. Harris, MD, Lexington Veterans Affairs Health Care System

Andrew M. Harris is the section chief of urology at the Lexington VA Health Care System and an assistant professor at the University of Kentucky. He is the director of the Lexington VA Interprofessional Fellowship Program in Patient Safety, as well as the Lexington VA chief resident in quality and safety for the General Surgery Program. His research is heavily focused on improving healthcare value, incorporating quality improvement and patient safety into training, and Lean implementation into healthcare. He is also a member of the American Urological Association’s Quality Improvement and Patient Safety Committee.


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Illustration of man in white uniform holding up a blood transfusion bag, and a doctor standing on 2 books, adding blood from a syringe into three test tubes.



How to Cite

Lancaster, E. A., Rhodus, E. K., Duke, M. B., & Harris, A. M. (2021). Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses. Patient Safety, 3(2), 78–91.



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