This case deals with failure to provide irradiated blood for patients with special transfusion needs such as those being treated with fludarabine.

Provide 4 concrete examples of how these errors may occur.

Concrete examples of how patients on fludarabine therapy may received incorrect (un-irradiated) blood include:

  • Ordering physician does not recognize that patient needs irradiated blood
  • Need for irradiated blood does not follow the patient from facility to facility
  • Need for irradiated blood is not flagged in the laboratory information system (LIS)
  • TS laboratory fails to retrieve patient history
  • LIS fails to identify patient as needing irradiated blood