Department of Transfusion Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
Clin Chem Lab Med. 2012 Nov;50(11):1935-43. doi: 10.1515/cclm-2012-0212.
Errors in the transfusion process can compromise patient safety. A study was undertaken at our center to identify the errors in the transfusion process and their causes in order to reduce their occurrence by corrective and preventive actions.
All near miss, no harm events and adverse events reported in the 'transfusion process' during 1 year study period were recorded, classified and analyzed at a tertiary care teaching hospital in North India.
In total, 285 transfusion related events were reported during the study period. Of these, there were four adverse (1.5%), 10 no harm (3.5%) and 271 (95%) near miss events. Incorrect blood component transfusion rate was 1 in 6031 component units. ABO incompatible transfusion rate was one in 15,077 component units issued or one in 26,200 PRBC units issued and acute hemolytic transfusion reaction due to ABO incompatible transfusion was 1 in 60,309 component units issued. Fifty-three percent of the antecedent near miss events were bedside events. Patient sample handling errors were the single largest category of errors (n=94, 33%) followed by errors in labeling and blood component handling and storage in user areas.
The actual and near miss event data obtained through this initiative provided us with clear evidence about latent defects and critical points in the transfusion process so that corrective and preventive actions could be taken to reduce errors and improve transfusion safety.
输血过程中的错误可能危及患者安全。我们中心进行了一项研究，以确定输血过程中的错误及其原因，以便通过纠正和预防措施减少其发生。
在印度北部的一家三级护理教学医院，记录、分类和分析了为期 1 年研究期间在“输血过程”中报告的所有接近伤害、无伤害和不良事件。
在研究期间，共报告了 285 起与输血相关的事件。其中，有 4 起不良事件（1.5%）、10 起无伤害事件（3.5%）和 271 起接近伤害事件（95%）。错误输注血液成分的比例为每 6031 个成分单位 1 次。ABO 不相容输血的比例为每 15077 个发出的成分单位或每 26200 个发出的 PRBC 单位 1 次，由于 ABO 不相容输血导致的急性溶血性输血反应为每 60309 个发出的成分单位 1 次。53%的前因接近伤害事件是床边事件。患者样本处理错误是错误中最大的类别（n=94，33%），其次是标签和血液成分处理以及在用户区域的储存错误。
通过这一举措获得的实际和接近伤害事件数据为我们提供了关于输血过程中潜在缺陷和关键点的明确证据，以便采取纠正和预防措施减少错误并提高输血安全性。
