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输血相关安全事件报告。

Safety incident reports associated with blood transfusions.

机构信息

Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York.

AABB Center for Patient Safety, AABB, Bethesda, Maryland.

出版信息

Transfusion. 2019 Sep;59(9):2827-2832. doi: 10.1111/trf.15429. Epub 2019 Jun 29.

DOI:10.1111/trf.15429
PMID:31254465
Abstract

BACKGROUND

Patient safety remains a critical issue in health care. Adverse events related to blood transfusion constitute a threat to patient safety. The aim of this study is to compare and contrast reporting trends of patient safety events that occur during the transfusion of blood components in pediatric and adult hospital care settings.

STUDY DESIGN AND METHODS

This is a multicenter analysis of reported patient safety incidents occurring during the administration of blood components for four children's and 21 adult hospitals from January 2010 through September 2017. Denominators were pediatric or adult transfusions per year for a subset of two pediatric and two adult hospitals able to provide denominators for the complete reporting period. Rates were calculated on the subset of four hospitals per 100,000 components transfused with Pearson's chi square for comparison (p < 0.05 as significant).

RESULTS

There were 1902 reports for an estimated 1.1 million transfusions: 358 reports from pediatric hospitals and 1544 reports from adult hospitals. From hospitals able to provide denominator data; there were 192 reports for 128,560 pediatric transfusions and 183 reports for 377,563 adult transfusions. The reporting rate per 100,000 components from these four hospitals was 149 for pediatric and 48 for adult reports (p < 0.01).

CONCLUSION

This analysis demonstrates the continued need for transfusion safety practices. The type of incident reports differed in the pediatric setting compared to the adult setting. Understanding patient safety event reporting trends related to blood transfusion will help target hemovigilance education and interventions to the appropriate patient populations.

摘要

背景

患者安全仍然是医疗保健中的一个关键问题。与输血相关的不良事件对患者安全构成威胁。本研究旨在比较和对比儿科和成人医院护理环境中输血期间发生的患者安全事件报告趋势。

研究设计和方法

这是对 2010 年 1 月至 2017 年 9 月期间在 4 家儿童医院和 21 家成人医院接受血液成分治疗期间发生的报告的患者安全事件进行的多中心分析。儿科或成人每年的输血次数为两个儿科和两个成人医院的一部分,这些医院能够为整个报告期提供分母。在四个医院中的每 100000 个成分中计算了率,使用 Pearson's chi square 进行比较(p < 0.05 为显著)。

结果

共有 1902 份报告,估计有 110 万次输血:儿科医院有 358 份报告,成人医院有 1544 份报告。从能够提供分母数据的医院来看,有 192 份报告涉及 128560 次儿科输血,183 份报告涉及 377563 次成人输血。这四所医院每 100000 个成分的报告率为儿科 149 例,成人 48 例(p < 0.01)。

结论

本分析表明,需要继续采取输血安全措施。儿科环境中的事件报告类型与成人环境不同。了解与输血相关的患者安全事件报告趋势将有助于针对适当的患者群体进行血液监测教育和干预。

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