233 Vox Sanguinis (2007) 92, 233–241 ORIGINAL PAPER © 2007 The Author(s) Journal compilation © 2007 Blackwell Publishing Ltd. DOI: 10.1111/j.1423-0410.2006.00885.x Blackwell Publishing Ltd Seven hundred and fifty-nine (759) chances to learn: a 3-year pilot project to analyse transfusion-related near-miss events in the Republic of Ireland D. Lundy, 1 S. Laspina, 1 H. Kaplan, 2 B. Rabin Fastman 2 & E. Lawlor 1 1 National Haemovigilance Office, Irish Blood Transfusion Service, National Blood Centre, Irish Blood Transfusion Service, Dublin 8, Ireland 2 Department of Pathology, College of Physicians & Surgeons, Columbia University, New York, NY 10032, USA Background The National Haemovigilance Office has collected and analysed reports on errors associated with transfusion since 2000. A 3-year pilot research project in near-miss event reporting commenced in November 2002. Materials and Methods Near-miss reports from 10 hospital sites were analysed between May 2003 and May 2005. The Medical Event Reporting System for Trans- fusion Medicine was used to collect and analyse the data. Root cause analysis was used to identify causes of error. Results A total of 759 near-miss events were reported. Near misses are occurring 18 times more frequently than adverse events causing harm. Sample collection was found to be the highest risk step in the work process and was the first site of error in 468 (62%) events. Of these, 13 (3%) involved samples taken from the wrong patient. Medical staff were frequently involved in error. The general wards and emergency department were identified as high-risk clinical areas, in addition, 78 (10%) events occurred within the transfusion laboratory. Three specific human and two system failures were shown to have been associated with the errors identified in this study. Conclusions This study confirms that near-miss events occur far more frequently than adverse events causing harm. Collecting near-miss data is an effective means of highlighting human and system failures associated with transfusion that may otherwise go unnoticed. These data can be used to identify areas where resources need to be targeted in order to prevent future harm to patients, improving the overall safety of transfusion. Key words: haemovigilance, MERS-TM, near-miss, transfusion safety. Received: 26 September 2006, revised 27 November 2006, accepted 28 November 2006, published online 19 January 2007 Background/introduction The National Haemovigilance Office (NHO) was established in 1999 to collect and analyse serious adverse events and reactions associated with transfusion in the Republic of Ireland. During the 5-year period from 2000 to 2004, approx- imately 875 000 blood components were issued from the Irish Blood Transfusion Service (IBTS) and a total of 778 reports of adverse events/reactions were received by the NHO [1]. Of these, 428 (55%) were adverse events, 13 involving ABO-incompatible red cell transfusions. This correlates to a risk of receiving an ABO-incompatible red cell transfusion at 1 : 49 169 units issued, suggesting that significant risks of error continue to be associated with transfusion which outweigh other more publicized risks such as viral infection. Similar findings have been reported through other haemovigilance systems [2]. Much work has been done to analyse adverse events in transfusion. Adverse event reporting systems, however, are reactive and by the time lessons have been learned, Correspondence: Ms Derval Lundy, National Haemovigilance Office, Irish Blood Transfusion Service, National Blood Centre, James’ St, Dublin 8, Ireland E-mail: derval.lundy@ibts.ie