Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
Transfusion. 2012 Jul;52(7 Pt 2):1622-7. doi: 10.1111/j.1537-2995.2012.03759.x.
Good blood banking practice requires that every effort should be made to detect any deviation or defect in blood bank products and to identify any potential risk to blood donor or recipient(s). We report the findings of an exercise that provide an insight into why feedback from the user side is crucial.
Various events involving blood bags and plateletpheresis kits and the corresponding appropriate actions instituted for remedial measures were recorded. These scattered events were recorded for 6 months following the use of a new batch of improved blood bags with add-on features. Several events related to plateletpheresis kits from three different manufacturers were also recorded for 1 year.
The affected blood bags were utilized with no untoward incident. The complaint was closed following satisfactory response from the blood bag manufacturing company that acted in a timely manner in addressing the root causes of the problems. However, corrective and preventive actions (CAPA) could not be implemented for plateletpheresis kits. The rate of undesirable events was higher with plateletpheresis kits as compared with whole blood bags (1.75% vs. 0.06%).
As defects or deviations that trigger the need for CAPA can stem from numerous sources, it is important to clearly identify and document the problems and level of risk so that appropriate investigations can be instituted and remedial actions can be taken in a timely manner. This study demonstrates the usefulness of a quality initiative to collate and analyze blood product faults in conjunction with blood product manufacturers.
良好的血库实践要求尽一切努力检测血库产品的任何偏差或缺陷,并识别献血者或受血者的任何潜在风险。我们报告了一项研究的结果,该研究深入了解了为什么用户反馈至关重要。
记录了涉及血袋和血小板采集套件的各种事件以及为补救措施而采取的相应适当行动。在使用具有附加功能的新批次改良血袋后,对这 6 个月内发生的这些分散事件进行了记录。还记录了来自三个不同制造商的血小板采集套件的几个相关事件,为期 1 年。
受影响的血袋得到了使用,没有发生任何不良事件。在血袋制造公司及时采取措施解决问题的根源后,投诉得到了满意的答复,并已结案。然而,血小板采集套件无法实施纠正和预防措施(CAPA)。与全血袋相比,血小板采集套件的不良事件发生率更高(1.75%对 0.06%)。
由于触发 CAPA 需要的缺陷或偏差可能来自多个来源,因此重要的是要清楚地识别和记录问题和风险级别,以便能够进行适当的调查并及时采取补救措施。本研究证明了与血液制品制造商合作,通过质量倡议来整理和分析血液制品故障的有用性。