Bedside Transfusion Errors

Abstract

The true incidence of bedside transfusion errors, i.e. those happening when blood products have left the blood bank, is underestimated because published figures rely on reporting of clinically relevant events or on indirect methods. The SAnGUIS project assessing blood practice in a prospective and randomized fashion for 6 elective surgical procedures gave the opportunity to trace all transfused units and to identify steps at risk during blood delivery in surgery. We considered transfusion of a wrong unit as a major error and poor execution or documentation as a recording error. Over 15 months, 808 patients out of 1,448 were transfused with 3,485 units. A total of 165 errors were found after blood products had left the blood banks. Seven were misidentifications (0.74% of patients, 0.2% of units). Eight other major errors occurred in 4 (0.5%) patients. Major errors occurred during nonemergency situations, in wards or intensive care units. The remaining ('recording') 150 errors consisted of misrecordings (61), mislabellings (6), or failures to document transfusions in the medical records (83). All errors were uneventful except one misidentification which induced a transient, yet unreported, reaction. The 'descending' inquiry method used for this study showed that most errors pass unnoticed and are therefore not reported. Measurement of error rates may constitute an important quality indicator. Retrospective information of this survey to the concerned staff people provided an impetus to take adequate measures to reduce these bedside errors.

Comparing near misses with actual mistransfusion events: a more accurate reflection of transfusion errors

“…Only 25% (7 out of 28) of transfusion errors resulted in mistransfusion, whereas 75% were averted, having been detected as near misses. Even this is probably an underestimate of the true number of events because errors outside the ABO blood group system (ABO-compatible errors) are less likely to be detected, sought after (Lumadue et al, 1997) or, as reported by the Belgian SANGUIS Group, a retrospective analysis is more likely to underestimate the number of errors as it relies on voluntary reporting of errors rather than the systematic approach to error detection, as in the case of prospective study (Baele et al, 1994).…”

A study of transfusion related adverse events at a tertiary care centre in North India: an initiative towards hemovigilance

“…Baele et al reported bedside transfusion errors occur in 12.4/ 1000 transfusions. 10 Goodnough estimated that the administrative errors were the most serious risks leading to Acute ABO incompatible hemolytic reactions. 11 Overall risk of acute hemolytic reactions in present study was 0.32 per thousand transfusions.…”

Code development of the national hemovigilance system and expansion strategies for hospital blood banks

“…[3] Some efforts have been made to scale measurements of noninfectious transfusion-related events, including MERS-TM,[2] the voluntary program SHOT,[4] the mandatory transfusion-related incidents/accidents/medical errors reporting system of the New York State Department of Health,[5] the French Haemovigilance System,[6] and Belgium's SANGUIS Group. [7] Near-miss events were estimated to be five times that of the actual events. [8] Although the hemovigilance system managed by the Red Cross is being demonstrated and executed as the primary reporting system, it cannot be established as a complete hemovigilance system without relationships to hospital blood banks.…”