Administration Safety of Blood Products - Lessons Learned from a National Registry for Transfusion and Hemotherapy Practice

Abstract

<b>Background: </b>Compared to blood component safety, the administration of blood may not be as safe as intended. The German Interdisciplinary Task Force for Clinical Hemotherapy (IAKH) specialized registry for administration errors of blood products was chosen for a detailed analysis of reports. <b>Methods: </b>Voluntarily submitted critical incident reports (n = 138) from 2009 to 2013 were analyzed. <b>Results: </b>Incidents occurred in the operation room (34.1%), in the ICU (25.2%), and in the peripheral ward (18.5%). Procedural steps with errors were administration to the patient (27.2%), indication and blood order (17.1%), patient identification (17.1%), and blood sample withdrawal and tube labeling (18.0%). Bedside testing (BST) of blood groups avoided errors in only 2.6%. Associated factors were routine work conditions (66%), communication error (36%), emergency case (26%), night or weekend team (39%), untrained personnel (19%). Recommendations addressed process and quality (n = 479) as well as structure quality (n = 314). In 189 instances, an IT solution would have helped to avoid the error. <b>Conclusions: </b>The administration process is prone to errors at the patient assessment for the need to transfuse and the application of blood products to patients. BST is only detecting a minority of handling errors. According to the expert recommendations for practice improvement, the potential to improve transfusion safety by a technical solution is considerable.

A national Transfusion Register of Irregular Antibodies and Cross (X)‐match Problems: TRIX, a 10‐year analysis

“…A complete overview of the antibody registrations per specificity and sex is shown in Table 2. Overall, anti-Es (11,955) have been registered most, followed by antibodies against K (9468), D (8276), M (7170), Le a (4620), C (4221), Wr a (4172), c (3779), Fy a (3694), C w (2376), Jk a (2319), Le b (1959) antibodies, respectively. A total of 5.6% of all TRIX registrations (304) concern rare antibodies and are not specified in Table 2.…”

“…With increased interhospital patient mobility, a shared database of patient records that can be accessed by transfusion laboratories from different hospitals can improve patient care. 10,11 The Dutch national database Transfusion Register of Irregular Antibodies and Cross (X)-match Problems (TRIX) was launched in 2007. In the TRIX database, information relevant for pretransfusion testing, such as RBC alloantibodies, human platelet antibodies, and allogeneic stem cell transplantations, is registered.…”

“…With increased interhospital patient mobility, a shared database of patient records that can be accessed by transfusion laboratories from different hospitals can improve patient care . The Dutch national database Transfusion Register of Irregular Antibodies and Cross (X)‐match Problems (TRIX) was launched in 2007.…”

Implementation and Effectiveness of a Bar Code–Based Transfusion Management System for Transfusion Safety in a Tertiary Hospital: Retrospective Quality Improvement Study

“…Although the application of new technology could simplify the complexity of routine procedures and an end-to-end electronic system could help further improve transfusion safety [4-7], the drive of using IT technologies to improve transfusion-related errors is lacking worldwide. Obstacles to the deployment of new technology include resistance to change, confusion regarding the best technology, and uncertainty regarding the return on investment [8].…”

Health Services Research

“…An analysis of errors occurring in the German transfusion system showed that the adherence to the extensive German transfusion guidelines (particularly with regard to transfusion needs) is low, and that transfusion safety might be improved by technical solutions such as barcode-or RFID-based scanner techniques [6].…”