New Jersey Department of Health

Clinical Laboratory Improvement Service

PO Box 361

Trenton, NJ 08625-0361

ERROR / ACCIDENT REPORT

Instructions:

1.	As of May 1989, in compliance with Chapter 8, State Administrative Code: Collection, Processing, Storage and Distribution of Blood, N.J.A.C. 8:8-5.2(c) and (d), errors and/or accidents that result in shipment of unsuitable blood or blood components, shall be reported to the Department within 10 days of recognition of the error.

2.	This requirement also applies: to any component that is unsuitable for distribution but as a result of an error is available for transfusion, fractionation, reagent production or research, and to any errors that result in the transfusion of blood, regardless of harm to the recipient.

3.	Keep a copy for your records and forward the original report to the above address. If more space is needed, attach additional sheets.

4.	If there are any questions, contact the Blood Bank unit at (609) 406-6829.
Name of Blood Bank

Telephone Number

Name of Person Completing the Form

Telephone Number

Date of Error

Date Error Detected

Type of Error
Infectious Disease Testing,
Specify Test:
Improperly Tested
Not Tested
Properly Tested but Improperly Interpreted or Labeled
ABO,
Specify:
Permanent Deferral,
Specify:
Confidential Unit Exclusion
Transfusion-Related Septicemia
Other, Specify:

CL-21

JUL 12	Page 1 of 2 Pages.

ERROR / ACCIDENT REPORT, Continued

Name of Blood Bank

Donation Number (s)

Components Prepared from each Donation Number

Components Transfused (List by Number)

Successful Recall(s) (List by Number)

Describe the Error

Describe Corrective Action(s) taken to prevent error from recurring.

Name of Blood Bank Director (Print)

Signature of Blood Bank Director	Date Reported

Forward completed Report to address listed above; retain a copy for your records

CL-21

JUL 12	Page 2 of 2 Pages.

CL-21, Error/Accident Report

CL-21, clinical lab improvement service, blood banks, error, accident report

ewhite

2001-03-23

NJDOH