三家医院的输血医学医疗事件报告系统（MERS-TM）的经验。

Experience with the medical event reporting system for transfusion medicine (MERS-TM) at three hospitals.

作者信息

Callum Jeannie L, Merkley Lisa L, Coovadia Ahmed S, Lima Ana P, Kaplan Harold S

机构信息

Department of Clinical Pathology, Sunnybrook and Women's College Health Sciences Centre, and The University of Toronto, 2075 Bayview Avenue, Toronto, Ont., Canada.

出版信息

Transfus Apher Sci. 2004 Oct;31(2):133-43. doi: 10.1016/j.transci.2004.07.007.

DOI:10.1016/j.transci.2004.07.007

PMID:15501417

Abstract

BACKGROUND

The MERS-TM assists hospital transfusion services to identify, analyze, and correct system events relating to the delivery of blood to patients.

METHODS

The MERS-TM system was used from February of 1999 to December 2002. All reported near-miss and actual events were recorded and analyzed.

RESULTS

During these 47 months, 4670 events were reported by the transfusion service. Of these events, 94% were classified as a near-miss event and 93% were detected before the blood product was administered. No ABO-incompatible transfusions were detected despite transfusion of 50,137 units of red blood cells. High severity events with the potential for patient harm accounted for 241 (5%) of the 4670 events. Nursing related events accounted for 188 (78%) of the high severity events. In one out of 4430 (0.023%) samples tested, a high severity sample-testing event was detected. In one out of 1550 (0.06%) samples collected, a high severity sample-collection event was detected.

CONCLUSION

An event reporting system is essential if one is to determine where and how often events are occurring within the transfusion process.

摘要

背景

中东呼吸综合征输血监测（MERS-TM）有助于医院输血服务部门识别、分析和纠正与向患者输血相关的系统事件。

方法

1999年2月至2002年12月使用MERS-TM系统。记录并分析所有报告的险些发生的事件和实际事件。

结果

在这47个月期间，输血服务部门报告了4670起事件。在这些事件中，94%被归类为险些发生的事件，93%在血液制品输注前被发现。尽管输注了50137单位红细胞，但未检测到ABO血型不相容的输血情况。4670起事件中有241起（5%）是可能对患者造成伤害的高严重度事件。护理相关事件占高严重度事件的188起（78%）。在4430个（0.023%）检测样本中，有1个检测到高严重度样本检测事件。在1550个（0.06%）采集样本中，有1个检测到高严重度样本采集事件。