Novelle QLL 2020 – welche Auswirkungen haben die neu empfohlenen Hämoglobin-Transfusionstrigger auf die klinische Versorgung?

Kotzerke, David; Costa, Maria Walter; Voigt, Jenny; Kleinhempel, Alisa; Schmidt, Michael; Söhnlein, Tim; Kaiser, Thorsten; Henschler, Reinhard

doi:10.1055/a-1669-3918

Cited by 1 publication

(1 citation statement)

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“…The indication for a red cell transfusion is defined via the pretransfusion hemoglobin value and the patient’s hypoxia risk status. 13 , 14 In patients without risk factors, a hemoglobin threshold of <7 g/dL (4.3mmol/L) is considered restrictive. If there are risk factors, it is set between 7 and 10 g/dL (4.3–6.2mmol/L).…”

Section: Resultsmentioning

confidence: 99%

Systematic Workup of Transfusion Reactions Reveals Passive Co-Reporting of Handling Errors

Nitsche,

Dreßler,

Henschler

2023

JBM

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Introduction Reporting of transfusion reactions is good practice and required by many guidelines. Errors in the transfusion chain can also lead to severe patient reactions and depend on active error reporting. We aimed to characterize transfusion incidents and asked whether workup of transfusion reactions may also contribute to revealing logistical errors. Methods Transfusion medical records from 2011 to 2019 at our tertiary medical centre, as well as forensic autopsy reports, digitized sections, and court records from 1990 to 2019 were analysed. A total of 230,845 components were transfused between 2011 and 2019 at our own institution. Results Overall, 322 transfusion incidents were reported. Of these, 279 were from our own institution, corresponding to a frequency of 0.12% of all transfusions. The distribution of reaction types is consistent with the literature, with allergic reactions (55.9%), febrile-non-hemolytic reactions (FNHTR, 24.2%), hemolytic reactions (3.4%) and other types at smaller frequencies (<3%). Twenty-nine (10.4%) of the 279 reports revealed logistical errors, including hemoglobin above guideline threshold (4.3%), incorrect or non-performed bedside tests (3.2%), inadequate patient identification (2.5%), laboratory and issuing errors, missed product checks or failure to follow recommendations (1.1% each). Eight of 29 (27.5%) of the logistical errors were detected by serendipity during workup of incident reports. In addition, 8/932 autopsy cases under code A14 (medical treatment errors) were found to be transfusion-associated (0.9%). Conclusion Systematic workup of transfusion incidents can identify previously undetected errors in the transfusion chain. Passive reporting of errors through the recording of side effects may serve as a tool to assess more closely assess the frequency and quality of handling errors in real life, and thus serve to improve patient safety.

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Section: Resultsmentioning

confidence: 99%