Gonzalez-Porras J R, Graciani I F, Alvarez M, Pinto J, Conde M P, Nieto M J, Corral M
Transfusion Service, Department of Hematology, University Hospital of Salamanca, Salamanca, Spain.
Vox Sang. 2008 Jul;95(1):52-6. doi: 10.1111/j.1423-0410.2008.01049.x. Epub 2008 Apr 2.
The greatest risk in transfusion medicine is actually human error, resulting in the use of the incorrect blood component. The aim of our study was to identify and evaluate the risk factors involved in the collection and labelling of pretransfusion blood samples.
We prospectively evaluated 6446 samples submitted to the blood bank for pretransfusion testing. Inappropriate samples were classified as 'mislabelled' or 'miscollected'. After 4 months of study, an educational approach was taken.
The frequency of inappropriately labelled samples was 6.45%. Such samples were associated with the use of addressograph labels (vs. hand-written labels) [23.4% vs. 1.4%, P < 0.0001], collection by clinical staff (vs. blood bank staff) [8.8% vs. 2.1%, P = 0.001] and emergency situations (vs. routine sampling) [10.1% vs. 6.1%, P = 0.005]. Following educational intervention, the percentage of inappropriately labelled samples decreased from 7.3% (pre-educational) to 5.8% (post-educational), P = 0.005.
Ongoing monitoring and analysis of labelling and collection should be mandatory in order to improve the safety of transfusion.
输血医学中最大的风险实际上是人为失误,这会导致使用错误的血液成分。我们研究的目的是识别和评估输血前血样采集与贴标签过程中涉及的风险因素。
我们前瞻性地评估了提交至血库进行输血前检测的6446份样本。不合适的样本被归类为“标签错误”或“采集错误”。经过4个月的研究后,采取了一种教育方法。
标签错误样本的发生率为6.45%。此类样本与使用地址ograph标签(与手写标签相比)[23.4%对1.4%,P<0.0001]、由临床工作人员采集(与血库工作人员相比)[8.8%对2.1%,P = 0.001]以及紧急情况(与常规采样相比)[10.1%对6.1%,P = 0.005]有关。经过教育干预后,标签错误样本的百分比从7.3%(教育前)降至5.8%(教育后),P = 0.005。
为提高输血安全性,应对标签和采集进行持续监测与分析。