Strauss Rachel, Downie Helen, Wilson Ann, Mounchili Aboubaker, Berry Brian, Cserti-Gazdewich Christine, Callum Jeannie
Queen's University, Kingston, Ontario, Canada.
Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Transfusion. 2018 Jul;58(7):1697-1707. doi: 10.1111/trf.14608. Epub 2018 Apr 17.
In Canada, transfusion-related errors are voluntarily reported to a tracking system with the goal to systematically improve transfusion safety. This report provides an analysis of sample collection (SC) and sample handling (SH) errors from this national error-tracking system.
Errors from 2006 to 2015 from 23 participating sites were extracted. A survey was conducted to obtain information regarding institutional policies. Samples received in the blood bank were used to calculate rates. "Wrong blood in tube" (WBIT) errors are blood taken from wrong patient and labeled with intended patient's information, or blood taken from intended patient but labeled with another patient's information.
A total of 42,363 SC and 14,666 SH errors were reported. Predefined low-severity (low potential for harm) and high-severity errors (potential for fatal outcomes) increased from 2006 to 2015 (low SC, SH: 13-27, 3-12 per 1000; high SC, SH: 1.9-3.7, 0.5-2.0 per 1000). The WBIT rate decreased from 12 to 5.8 per 10,000 between 2006 and 2015 (p < 0.0001). The overall WBIT rate was 6.2 per 10,000, with variability by site (median, 0.3 per 10,000; range, 0-17 per 10,000). Sites with error detection mechanisms, such as regrouping second sample requirements, had lower error rates than sites that did not (SC, SH: 12, 1 per 1000 samples vs. 17, 3 per 1000 samples; p < 0.0001).
WBIT rates decreased significantly. Low-severity error rates are climbing likely due to increased ascertainment and reporting. Prevention studies are necessary to inform changes to blood transfusion standards to eliminate these errors.
在加拿大，与输血相关的错误会被自愿报告至一个追踪系统，目的是系统性地提高输血安全性。本报告对来自这个国家错误追踪系统的样本采集（SC）和样本处理（SH）错误进行了分析。
提取了2006年至2015年23个参与站点的错误信息。开展了一项调查以获取有关机构政策的信息。使用血库中接收的样本计算发生率。“管内血型错误”（WBIT）错误是指从错误患者采集血液并标注为预期患者的信息，或者从预期患者采集血液但标注为另一名患者的信息。
共报告了42363起样本采集错误和14666起样本处理错误。2006年至2015年，预定义的低严重程度（低伤害可能性）和高严重程度错误（致命后果可能性）有所增加（低样本采集、样本处理：每1000例中分别从13起增至27起、从3起增至12起；高样本采集、样本处理：每1000例中分别从1.9起增至3.7起、从0.5起增至2.0起）。2006年至2015年期间，WBIT发生率从每10000例12起降至5.8起（p < 0.0001）。总体WBIT发生率为每10000例6.2起，各站点存在差异（中位数为每10000例0.3起；范围为每10000例0至17起）。设有错误检测机制（如重新分组二次样本要求）的站点错误率低于未设该机制的站点（样本采集、样本处理：每1000份样本分别为12起、1起，对比每1000份样本17起、3起；p < 0.0001）。
WBIT发生率显著下降。低严重程度错误率上升可能是由于确定和报告的增加。有必要开展预防研究，为改变输血标准提供依据，以消除这些错误。
