Jimenez-Marco T, Clemente-Marin G, Girona-Llobera E, Sedeño M, Muncunill J
Fundació Banc de Sang i Teixits de les Illes Balears, Majorca, Spain.
Transfus Apher Sci. 2012 Aug;47(1):49-55. doi: 10.1016/j.transci.2012.04.005. Epub 2012 May 28.
In recent years, there has been a gradual increase in mistransfusion events reported to our Regional Hemovigilance Division. Our objective was to design a transfusion practice nursing survey to study the causes of the increasing mistransfusion rate.
Mistransfusion rates between 2007 and 2009 were obtained from the Balearic Island Hemovigilance Division (BIHVD), one of the 17 regional HV divisions in the Spanish Hemovigilance network. The BIHVD designed a transfusion practice nursing survey to study the causes of the increasing mistransfusion rate. Every year, 614 nurses carry out around 47,000 transfusions in our region. Data were collected through voluntary, anonymous, questionnaires which included questions about socio-professional factors, transfusion training and education, together with transfusion practice questions both related and unrelated to guidelines and nurses' attitudes. Multiple regression analysis was used to investigate which mistransfusion prediction factors were most accurate.
The survey response rate was 363 out of 614 (59.12%). Marked deficits in nurses' education and training and low transfusion frequency had a strong negative impact on the incidence of transfusion errors (r=-0.70; p=0.01). This is supported by evidence that the performance of well-trained nurses who transfused either daily or weekly and strictly followed transfusion guidelines was associated with a lower mistransfusion rate (r=-0.93; p<0.01).
Nurses' training, education and how frequently a nurse transfuses are the key factors for best transfusion practice in our region. This study illustrates the feasibility of using Hemovigilance resources to investigate the causes of mistransfusion.
近年来，向我们地区血液警戒部门报告的输血差错事件呈逐渐上升趋势。我们的目标是设计一项输血实践护理调查，以研究输血差错率上升的原因。
2007年至2009年期间的输血差错率数据来自巴利阿里群岛血液警戒部门（BIHVD），它是西班牙血液警戒网络17个地区血液警戒部门之一。BIHVD设计了一项输血实践护理调查，以研究输血差错率上升的原因。每年，我们地区有614名护士进行约47000次输血。数据通过自愿、匿名问卷收集，问卷内容包括社会职业因素、输血培训与教育方面的问题，以及与指南相关和不相关的输血实践问题和护士态度。采用多元回归分析来研究哪些输血差错预测因素最为准确。
614名护士中有363名（59.12%）参与了调查。护士教育和培训方面的明显不足以及输血频率较低对输血差错发生率有强烈的负面影响（r = -0.70；p = 0.01）。有证据支持这一点，即每天或每周进行输血且严格遵循输血指南的训练有素的护士的表现与较低的输血差错率相关（r = -0.93；p < 0.01）。
护士的培训、教育以及输血频率是我们地区最佳输血实践的关键因素。本研究说明了利用血液警戒资源调查输血差错原因的可行性。
