Transfusion errors and management

Koh, Mickey B.C.; Alcantara, Ramir

doi:10.1111/j.1751-2824.2009.01273.x

Cited by 5 publications

(6 citation statements)

References 18 publications

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“…Sadly, much less progress has been made in eliminating acute haemolytic transfusion reactions caused by administering ABO‐incompatible blood. Most of these reactions are secondary to human error, most notably specimen misidentification [2, 4–6].…”

Section: Discussionmentioning

confidence: 99%

“…HIV and HCV) have become extremely rare, with an estimated rate of 1 transmission per 2 million transfusions [8]. Sadly, much less progress has been made in eliminating acute [2,[4][5][6]. Of course, error in sample identification is not only a problem for the blood bank but for the laboratory in general [1].…”

Section: Discussionmentioning

confidence: 99%

“…Despite all these efforts, most testing errors occur in the preanalytical stage, with specimen identification and labelling being the biggest culprits [1]. Indeed, a recent review of transfusion-associated errors has identified preanalytical (non-blood bank) errors as the leading cause of mistransfusions worldwide [2].…”

Section: Introductionmentioning

confidence: 99%

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‘Wrong blood in tube’: solutions for a persistent problem

Ansari

Szállaśi

2010

Vox Sanguinis

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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‘Wrong blood in tube’: solutions for a persistent problem

Ansari

Szállaśi

2010

Vox Sanguinis

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“…Regular training, as well as retraining of implicated personnel, can be beneficial in improving rates of unwanted laboratory errors. 24 …”

Section: Discussionmentioning

confidence: 99%

Prevalence of Near-miss Events of Transfusion Practice and Its Associated Factors amongst House Officers in a Teaching Hospital

2021

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Objectives: A near miss in transfusion practice is defined as a deviation from standard procedures discovered before transfusion and can lead to a transfusion error. Information on near-miss events provides pivotal data on areas of improvement to prevent actual errors in the future. Our study sought to determine the prevalence and rate of near-miss events and their associated factors amongst house officers (HO) in Hospital Universiti Sains Malaysia. Methods: The initial part of this study is a descriptive cross-sectional study involving data collection from all requests sent for group, screen, and hold (GSH) and group and cross match (GXM) tests from 2011 to 2017. The association between sociodemographic, workplace, and experience factors with near-miss events amongst HO was analyzed with a case-control study using logistic regression. Results: We reported 83 near-miss events with a prevalence of 0.034% (95% confidence interval 0.027–0.042). The rate of near-miss events was one in every 2916 requests. The mean reporting rate was 11.9 events per year. Clinical near miss predominated at 89.2% compared to 10.8% laboratory near miss. Mislabeled events (33.7%) were more than miscollected events (10.8%). HO were implicated with most events (83.1%). Most events were predominantly in the medical and obstetrics and gynecology wards amounting to 31.3% each. We found a significant association between the ages of HO with near-miss events. Conclusions: The prevalence of near-miss events in our hospital was relatively low. Our study has shown areas for improvement include improving sampling practices in clinical areas, adequate training of laboratory technicians, and providing proper transfusion education. Interventions such as encouraging compliance to guidelines and training in clinical and laboratory areas to minimize the risk of mistransfusion should be considered.

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“…In a collation of data between 2002–2008, sampling and request errors together accounted for 75% of the total reported errors. They also identified that near miss errors were growing in number over the years which was likely a reflection of greater compliance with reporting .…”

Section: Introductionmentioning

confidence: 99%

Education‐based interventions to minimize sampling errors in transfusion

Mel

Lim

Soekojo

et al. 2016

ISBT Science Series

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Background and Objectives Sampling errors are an important preventable cause of incorrect blood component transfusion. A variety of measures designed to minimize 'Wrong Blood in Tube' errors have been published, but they are often costly and difficult to implement in resource-limited settings. The aim of our study was to describe the impact of two education-based interventions on the rate of transfusion sampling errors at our institution. Materials and MethodsWe prospectively collected data on transfusion sampling errors between 2001 and 2014. Sampling errors were categorized as types 1, 2, 3, 4 and 5. The 'Quest' project focusing on the education of staff on transfusion sampling was carried out in 2001. We subsequently trained nurses to perform transfusion sampling in 2008.Results A total of 75 sampling errors were identified during the study period. The 'Quest' project resulted in a reduction in sampling errors as a percentage of all type and screen (T&S) specimens received. Sampling errors comprised 0Á05% of total T&S specimens in 2001 compared to 0Á01% in 2007 (P = 0Á014). Between 2002 and 2014, sampling errors comprised a median 0Á02% of total T&S specimens received. Training of nurses in T&S sampling resulted in a reduction of type 3 sampling errors from 0Á02% in 2008 to 0 in 2013, (P = 0Á01). ConclusionsOur study highlights that simple, education-based measures can be highly effective at reducing the incidence of sampling errors. The interventions we describe maybe easily implemented in resource-limited settings.

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Transfusion errors and management

Cited by 5 publications

References 18 publications

‘Wrong blood in tube’: solutions for a persistent problem

‘Wrong blood in tube’: solutions for a persistent problem

Prevalence of Near-miss Events of Transfusion Practice and Its Associated Factors amongst House Officers in a Teaching Hospital

Education‐based interventions to minimize sampling errors in transfusion

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