WBIT rates decreased significantly. Low-severity error rates are climbing likely due to increased ascertainment and reporting. Prevention studies are necessary to inform changes to blood transfusion standards to eliminate these errors.

Question 1 (a) We have local institutional guidelines to cover the use of therapeutic granulocyte infusions. The petermac site does not use prophylactic granulocytes, but our sister site with whom we are merging this year has used them on a couple of occasions.Question 2 (a) yes (b) Usage is increasing over time due to recognition of benefit, availability of a pool granulocyte product to intervene while donor granulocytes are organised

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Background:In situ simulation shows promise as an effective training tool for trauma; however, its disruptive nature is a major downside. Although the benefits of in situ simulation in trauma have been described, the potential perceived harms of running an unscheduled simulation using working staff are unknown. The aim of this study is to assess trauma team members' perceptions regarding the value of in situ simulation relative to its perceived impact on patient care. Methods: We conducted a longitudinal survey study including all members of the multidisciplinary trauma team at the Halifax Infirmary, a level 1 trauma centre in Nova Scotia. Following an in situ simulation, participants were given a 10-question survey with answers on a 5-point Likert scale. Results: A total of 61 surveys were collected. Survey respondents were grouped into allied health (nurses, paramedics, respiratory therapists; 44%), learners (residents and medical students; 44%) and other (staff physicians, those who did not specify their role; 12%). Respondents felt that participating in the in situ simulation delayed (28%) or compromised patient care (5%) infrequently. No respondents felt that patients were harmed. In situ simulation was felt to identify important safety issues (70%), improve trauma team communication (89%) and improve trauma patient care (89%). The in situ simulation was considered enjoyable (92%) and was identified as a good educational experience (95%). It was felt by participants that simulations should continue to be done in situ in the trauma bay rather than in a sim laboratory (54%). Conclusion:The trauma in situ simulation program at the Halifax Infirmary is not felt to cause delays or compromise patient care. The program is considered to be a good learning opportunity that identifies safety issues and improves patient care. Epidemiology of submersion injuries inCanadian children and adolescents: 1990-2018.

BACKGROUND: The blood transfusion chain is complex and error-prone. The key first step is patient registration for identification and linking to past medical and transfusion history. In Canada, transfusion-related errors are voluntarily reported to a national web-based database (Transfusion Error Surveillance System [TESS]). This project focuses specifically on the subset of registration errors impacting transfusion care in Canada. OBJECTIVE: To characterize registration-related transfusion errors in Canada between 2008 and 2017, including where, when, and why the errors occurred METHODS: A retrospective study was conducted on transfusion errors reported to TESS between January 2008 and December 2017. Errors reportable to TESS are defined as any deviation from standard operating procedures. Errors relating to patient registration and patient armbands were extracted. Data were available from 26 sentinel sites in three provinces. Volume of specimens received in the transfusion laboratory was used as denominator data where available. RESULTS: 554 errors pertaining to registration or patient armbands were reported, for a global error rate of 3.4/10,000 (range 0-18, median 1.4 [IQR 0-5.9]) (Figure 1). Errors were typically discovered before laboratory sample testing (n=222, 42%); 17% were discovered after product issue but before infusion (n=90). Errors most commonly occurred in outpatient clinics or procedure units (30% [range 0-100%]) and in emergency departments (24% [0%-100%]). The patient experienced a consequence in 11% (0%-75%) of errors but none resulted in transfusion reactions. The most frequent reports were name errors (29% [0%-100%]), duplicate patient registrations (27% [0%-100%]), and missing armbands (10% [0%-75%]) (Figure 2). CONCLUSION: Registration errors affect transfusion at every step and location in the hospital. Rates vary widely and differ by nature across sites. Further research into drivers of this heterogeneity is warranted to identify best preventative practices. This work was supported by the Public Health Agency of Canada and the Canadian Blood Services Program Support Award. Figure 1. Rate of error was calculated for sites with available denominator data from 2008 to 2015. Figure 2. Errors were categorized by site and by type: duplicate registration (multiple records existing for a single patient), doppelganger (confusion between records of two or more patients with similar identifiers), comingling (two or more patients using the same medical record file), missing patient armband, incorrect patient armband, name error (misspelled, missing, or incorrect), wrong date of birth, wrong sex, patients presenting another person's identification at registration, mistyping of medical record numbers, incorrect medical record numbers, errors in provincial health insurance numbers, and other errors. Numerical totals of errors at each site are given. Disclosures No relevant conflicts of interest to declare.