Incorporating the entity of under‐transfusion into hemovigilance monitoring: Documenting cases due to lack of inventory

Abstract

Background Under‐transfusion is an underreported entity within most hospitals and hemovigilance systems. While critical blood shortages are being reported more frequently, without incident codes to document instances of under‐transfusion due to lack of inventory, estimating its impact on patient care as it relates to hemotherapy (HT) has hampered our ability to assess and inform strategic initiatives to combat inventory issues as well as prepare for future blood supply threats. Study Design and Method An 11‐member working group of the AABB (Association for the Advancement of Blood and Biotherapies) Hemovigilance Committee was formed in October 2020 to study the topic of under‐transfusion including its potential causes and clinical expressions. The group was also charged with proposing simple definition/incident codes to be used by hemovigilance systems to document such instances. Results The working group proposed four simple incident codes under the new process code—No Blood (NB)—that can be used by hemovigilance systems to appropriately document instances of under‐transfusion due to lack of inventory. The codes were described as: (1) NB 01—Inventory less than usual level due to supplier shortage; (2) NB 02—Demand for blood product exceeding usual inventory levels; (3) NB 03—Substitution with incompatible/inappropriate units; and (4) NB 04—Suboptimal dose/no transfusion given. Conclusion The adoption of these codes within hemovigilance systems globally would assist in recognition and reporting instances of under‐transfusion due to inventory, thus supporting development of better collection strategies, inventory management techniques as well as effective policies to improve blood safety and availability.

Blood conservation strategies at United States hospitals during the COVID‐19 pandemic: Findings from a multi‐institutional analysis ‐ International Society of Blood Transfusion survey

“…In fact, the AABB assembled a group of researchers to define undertransfusion hemovigilance codes in late 2020 which were recently published to increase its recognition. 36 Though definitions now exist when blood products are limited, undertransfusion remains difficult to assess outside of a laboratory setting, as health care providers typically make transfusion decisions without blood bank consultation. Moving forward, novel means of assessing undertransfusion may be developed along with implementation of hemovigilance definitions.…”

“…Undertransfusion is of particular importance as it is considered both a transfusion complication and error. In fact, the AABB assembled a group of researchers to define undertransfusion hemovigilance codes in late 2020 which were recently published to increase its recognition 36 . Though definitions now exist when blood products are limited, undertransfusion remains difficult to assess outside of a laboratory setting, as health care providers typically make transfusion decisions without blood bank consultation.…”

Mini-Review on Haemovigilance: An Indian Perspective

“…The majority of these errors are the result of failure to follow procedures, or inadequate or unclear procedures [45,46].…”

Mini-Review on Haemovigilance: an Indian Perspective

“…Reports from the UK (2005) indicate that nearly 60% of adverse events associated with transfusion are a result of 'wrong blood to the wrong patient [44]. The majority of these errors are the result of failure to follow procedures, or inadequate or unclear procedures [45,46].…”