Near miss event: Sentinel to identifying catastrophic errors in transfusion chain

Although undesirable, near-miss events bring to light those previously overlooked areas and aid in training for strengthening the weaker “error-generating” links in the transfusion chain. These events may occur at the very first interaction with the patient at the hospital registration desk. Here, we present a case of a near-miss event, where an ABO-incompatible transfusion was averted, involving a patient misidentification error at the hospital registration desk, because of checks in the blood center information software.