Safety incident reports associated with blood transfusions

Abstract

BACKGROUND Patient safety remains a critical issue in health care. Adverse events related to blood transfusion constitute a threat to patient safety. The aim of this study is to compare and contrast reporting trends of patient safety events that occur during the transfusion of blood components in pediatric and adult hospital care settings. STUDY DESIGN AND METHODS This is a multicenter analysis of reported patient safety incidents occurring during the administration of blood components for four children's and 21 adult hospitals from January 2010 through September 2017. Denominators were pediatric or adult transfusions per year for a subset of two pediatric and two adult hospitals able to provide denominators for the complete reporting period. Rates were calculated on the subset of four hospitals per 100,000 components transfused with Pearson's chi square for comparison (p < 0.05 as significant). RESULTS There were 1902 reports for an estimated 1.1 million transfusions: 358 reports from pediatric hospitals and 1544 reports from adult hospitals. From hospitals able to provide denominator data; there were 192 reports for 128,560 pediatric transfusions and 183 reports for 377,563 adult transfusions. The reporting rate per 100,000 components from these four hospitals was 149 for pediatric and 48 for adult reports (p < 0.01). CONCLUSION This analysis demonstrates the continued need for transfusion safety practices. The type of incident reports differed in the pediatric setting compared to the adult setting. Understanding patient safety event reporting trends related to blood transfusion will help target hemovigilance education and interventions to the appropriate patient populations.

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

“…In addition to adverse events, we found actively reported administrative and logistic errors in about 13% of the reports, corresponding to a rate of 1.26/10.000 transfusions (0.12%). Vossoughi et al 18 report an error rate of about 0.15% of all transfusions by active reporting. Similarly, the British SHOT system in the 2021 report 20 summarized 2569 errors, which corresponds to a reported error rate of approximately 0.1%.…”

Notificación de incidentes relacionados con la atención a la salud en un hospital docente

“…Se observa que los incidentes más reportados, con la excepción de flebitis y cirugías, están de acuerdo con la literatura, sólo con algunas variaciones en términos porcentuales (12,14,15,17,(19)(20)(21)27,28) . Un estudio realizado en 12 grandes hospitales de la región metropolitana de Salvador -Bahía reportó cómo la mayoría de los eventos adversos lesiones por presión (88,9%), caídas (77,8%), errores de medicación (75%), eliminación no programada de drenajes y tubos (42,9%) y fallas en la identificación del paciente (33,3%) (24) .…”

Redesign of a Transfusion Issue Form Using Human Factors Science

“…performed procedure in the United States and, apart from infectious disease concerns, are generally believed to be safe. However, they do represent a significant risk to patients, as every transfusion (unit of blood) must be carefully matched and tracked throughout the process to be certain that the patient receives the correct blood type (Vossoughi et al, 2019). An incorrect blood type can result in destruction of the transfused red blood cells (hemolysis), resulting in a cascade of events that can lead to increased level of care, permanent organ damage, or death.…”