Steinsvåg Christine Torsvik, Espinosa Aurora, Flesland Øystein
The Norwegian Knowledge Centre for the Health Services, Norway; Department for Clinical Immunology and Transfusion Medicine, Sørlandet Hospital HF, Kristiansand, Norway.
Transfus Apher Sci. 2013 Dec;49(3):548-52. doi: 10.1016/j.transci.2013.09.013. Epub 2013 Oct 10.
The purpose of a haemovigilance system is to identify complications related to transfusion or blood donation, analyze them and learn in order to avoid complications in the future. The Norwegian Haemovigilance System (Troll) started as a voluntary, professionally led reporting system in 2004. In 2007 haemovigilance became an authority task, according to the EU blood directive, and reporting of serious adverse reactions and serious adverse events became mandatory. The Norwegian Directorate of Health became responsible for the system and asked The Norwegian Knowledge Centre for the Health Services to run it. Results from the first eight years of reporting are presented. A total of 2607 transfusion complications or incorrect blood component transfused (IBCT) have been reported (127 per 100,000 transfusions). Most transfusion reactions are mild. The most frequently reported are febrile non-hemolytic and mild allergic reactions. Serious adverse reactions such as anaphylaxis, TRALI and hemolytic transfusion reactions occur, but are rare. One incident of bacterial transmission and four incidents of viral transmission have been reported, among them one case of HCV transmission. No incidents of transmission of HIV or hepatitis B have been reported. IBCT was reported 168 times. Our data are comparable with data from other countries. Recommendations from the haemovigilance system are included in local and national guidelines. Increased knowledge of haemovigilance among physicians and nurses can lead to improved transfusion safety. It is safe to receive blood in Norway, but serious adverse reactions do occur. Our reporting system seems to be well accepted. We have not yet been able to document any change of practice that has lead to a reduction in the number of complications.
血液警戒系统的目的是识别与输血或献血相关的并发症，对其进行分析并从中吸取经验教训，以避免未来出现并发症。挪威血液警戒系统（Troll）始于2004年，是一个由专业人员主导的自愿报告系统。根据欧盟血液指令，2007年血液警戒成为一项官方任务，严重不良反应和严重不良事件的报告成为强制性要求。挪威卫生局负责该系统，并委托挪威卫生服务知识中心来运营。本文呈现了头八年的报告结果。共报告了2607例输血并发症或错误输血（IBCT）（每10万次输血中有127例）。大多数输血反应为轻度。报告最多的是发热性非溶血性反应和轻度过敏反应。严重不良反应如过敏反应、输血相关急性肺损伤和溶血性输血反应确实会发生，但很罕见。报告了1起细菌传播事件和4起病毒传播事件，其中1例为丙型肝炎病毒传播。未报告艾滋病病毒或乙型肝炎传播事件。IBCT报告了168次。我们的数据与其他国家的数据具有可比性。血液警戒系统的建议已纳入地方和国家指南。医生和护士对血液警戒知识的增加可提高输血安全性。在挪威接受输血是安全的，但严重不良反应确实会发生。我们的报告系统似乎得到了广泛认可。我们尚未能够证明任何实践上的改变导致了并发症数量的减少。
