Robillard P, Nawej K I, Jochem K
Quebec Public Health Institute, 4835 Christophe-Colomb, Room 100, Montreal, Que., Canada.
Transfus Apher Sci. 2004 Oct;31(2):111-22. doi: 10.1016/j.transci.2004.07.005.
Following federal and provincial reviews of the blood system, the Canadian province of Quebec passed a series of legislative and administrative measures to improve blood safety, including the establishment of a hemovigilance system, and made infrastructure and human resource investments to support their implementation. The Quebec hemovigilance system was inspired by the French system using similar data elements and case definitions, grading of severity and determination of likelihood of association with transfusion for adverse transfusion events (ATE). The Quebec system also monitors transfusion incidents without adverse consequences such as "incorrect blood component transfused" (IBCT) and near-miss events. Accurate rate estimates are possible through the collection of denominator data on the number of blood products transfused. This paper describes the Quebec hemovigilance system and reports on ATE (including IBCT but excluding near-miss events) associated with blood components notified in 2000 and 2001, the first two years of implementation. The Quebec hemovigilance system is voluntary, but hospital participation in 2000 and 2001 represented 80% and 82% of transfused products, respectively. Notified ATE (including IBCT) increased 78% between 2000 and 2001 primarily because of better reporting of minor adverse reactions. In 2001, the overall ATE rate was 3.5 per 1000 blood components transfused. Despite an overall increase in reported ATE, rates for some serious ATE decreased in the second year, including ABO-incompatible transfusions, acute hemolytic reactions and bacterial contamination.
在联邦和省级对血液系统进行审查之后，加拿大魁北克省通过了一系列立法和行政措施以提高血液安全，包括建立血液警戒系统，并进行了基础设施和人力资源投资以支持这些措施的实施。魁北克血液警戒系统的灵感来源于法国系统，采用了类似的数据元素、病例定义、严重程度分级以及输血不良事件（ATE）与输血关联可能性的判定方法。魁北克系统还监测没有不良后果的输血事件，如“输注错误血液成分”（IBCT）和险些发生的事件。通过收集输注血液制品数量的分母数据，可以得出准确的发生率估计值。本文描述了魁北克血液警戒系统，并报告了2000年和2001年（实施的头两年）所通报的与血液成分相关的ATE（包括IBCT，但不包括险些发生的事件）。魁北克血液警戒系统是自愿性的，但2000年和2001年医院的参与率分别占输注产品的80%和82%。2000年至2001年间，所通报的ATE（包括IBCT）增加了78%，主要原因是对轻微不良反应的报告有所改善。2001年，总体ATE发生率为每1000次输注血液成分中有3.5例。尽管报告的ATE总体有所增加，但在第二年，一些严重ATE的发生率有所下降，包括ABO血型不合输血、急性溶血反应和细菌污染。
