Sidhu Meena, Meenia Renu, Akhter Naveen, Sawhney Vijay, Irm Yasmeen
Department of Transfusion Medicine, Government Medical College, Jammu, Jammu and Kashmir, India.
Asian J Transfus Sci. 2016 Jan-Jun;10(1):48-52. doi: 10.4103/0973-6247.175402.
Errors in the process of pretransfusion testing for blood transfusion can occur at any stage from collection of the sample to administration of the blood component. The present study was conducted to analyze the errors that threaten patients' transfusion safety and actual harm/serious adverse events that occurred to the patients due to these errors.
The prospective study was conducted in the Department Of Transfusion Medicine, Shri Maharaja Gulab Singh Hospital, Government Medical College, Jammu, India from January 2014 to December 2014 for a period of 1 year. Errors were defined as any deviation from established policies and standard operating procedures. A near-miss event was defined as those errors, which did not reach the patient. Location and time of occurrence of the events/errors were also noted.
A total of 32,672 requisitions for the transfusion of blood and blood components were received for typing and cross-matching. Out of these, 26,683 products were issued to the various clinical departments. A total of 2,229 errors were detected over a period of 1 year. Near-miss events constituted 53% of the errors and actual harmful events due to errors occurred in 0.26% of the patients. Sample labeling errors were 2.4%, inappropriate request for blood components 2%, and information on requisition forms not matching with that on the sample 1.5% of all the requisitions received were the most frequent errors in clinical services. In transfusion services, the most common event was accepting sample in error with the frequency of 0.5% of all requisitions. ABO incompatible hemolytic reactions were the most frequent harmful event with the frequency of 2.2/10,000 transfusions.
Sample labeling, inappropriate request, and sample received in error were the most frequent high-risk errors.
输血前检测过程中的错误可能发生在从样本采集到血液成分输注的任何阶段。本研究旨在分析威胁患者输血安全的错误以及因这些错误导致患者发生的实际伤害/严重不良事件。
本前瞻性研究于2014年1月至2014年12月在印度查谟政府医学院斯里·马哈拉贾·古拉布·辛格医院输血医学科进行，为期1年。错误被定义为任何偏离既定政策和标准操作程序的情况。险些发生的事件被定义为那些未影响到患者的错误。还记录了事件/错误发生的地点和时间。
共收到32672份输血及血液成分配型的申请。其中，26683份产品发放给了各个临床科室。在1年的时间里共检测到2229起错误。险些发生的事件占错误的53%，因错误导致的实际有害事件发生在0.26%的患者中。样本标签错误占所有收到申请的2.4%，血液成分申请不当占2%，申请表格上的信息与样本信息不匹配占1.5%，这些是临床服务中最常见的错误。在输血服务中，最常见的事件是误收样本，占所有申请的0.5%。ABO血型不合的溶血性反应是最常见的有害事件，发生率为每10000次输血2.2例。
样本标签、申请不当和误收样本是最常见的高风险错误。
