NHS Blood & Transplant, John Radcliffe Hospital, Oxford OX3 9BQ, UK.
Vox Sang. 2011 Jan;100(1):46-59. doi: 10.1111/j.1423-0410.2010.01366.x.
Audits of practice and incident reporting, most notably to national haemovigilance schemes, indicate that poor hospital transfusion practice is frequent and occasionally results in catastrophic consequences for patients. Improvements in practice are needed and depend on a combined approach including a better understanding of the causes of errors; a reduction in the complexity of routine procedures taking advantage of new technology systems, which enforce agreed guidelines and policies; the setting and regular monitoring of performance standards for key aspects of the hospital transfusion process, improved organisation of transfusion in hospitals and staff training; and further research on the safe and effective use of blood and alternatives to donor blood. There needs to be a greater recognition that 'transfusion safety' applies to the hospital transfusion process as well as the contents of blood bags and that resources need to be provided for the improvement of transfusion safety and management in hospitals commensurate to their importance.
实践和事件报告的审核，尤其是向国家血液警戒计划的报告，表明医院输血实践中的不良做法很常见，偶尔会给患者带来灾难性的后果。需要改进实践，这取决于综合方法，包括更好地了解错误的原因；利用新技术系统简化常规程序，该系统强制执行商定的准则和政策；设定和定期监测医院输血过程关键方面的绩效标准，改善医院的输血组织和员工培训；并进一步研究血液的安全有效使用以及替代供者血液的方法。需要更加认识到，“输血安全”不仅适用于血袋内容物，也适用于医院输血过程，并且需要为改善医院的输血安全和管理提供资源，其重要性应与之相称。
