Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Blood Transfusion and Cell Therapy, Nagoya City University Hospital, Nagoya, Japan.
Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Hematology and Oncology, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan.
Transfus Apher Sci. 2020 Jun;59(3):102735. doi: 10.1016/j.transci.2020.102735. Epub 2020 Jan 27.
Despite recent progress in blood systems, transfusion errors can occur at any time from the moment of collection through to the transfusion of blood and blood products. This study investigated the actual statuses of blood transfusion errors at institutions of all sizes in Aichi prefecture.
We investigated 104 institutions that perform 98 % of the blood transfusions in Aichi prefecture, and investigated the errors (incidents/accidents) that occurred at these facilities over 6 months (April to September, 2017). Incident/accident data were collected from responses to questionnaires sent to each institution; these were classified according to the categories and risk levels.
Ninety-seven of the 104 institutions (93.3 %) responded to the questionnaire; a total of 688 incidents/accidents were reported. Most (682 cases; 99.2 %), were classified as risk level 2; however, 6 were level 3 and over, which included problems with autologous transfusion and inventory control. Approximately one-half of the incidents/accidents (394 cases; 57.3 %), were related to verification and the actual administration of blood products at the bedside; more than half of these incidents/accidents occurred at large-volume institutions. Meanwhile, a high frequency of incidents/accidents related to transfusion examination and labeling of blood products was observed at small- or medium-sized institutions. The reasons for most of these errors were simple mistakes and carelessness by the medical staff.
Our results emphasize the importance of education, operational training, and compliance instruction for all members of the medical staff despite advances in electronic devices meant to streamline transfusion procedures.
尽管血液系统在最近取得了进展，但从采集到输血的整个过程中，任何时候都可能发生输血错误。本研究调查了爱知县各级医疗机构的实际输血错误情况。
我们调查了爱知县 98%的输血机构（共 104 家），并调查了这些机构在 6 个月（2017 年 4 月至 9 月）期间发生的错误（事件/事故）。通过向每个机构发送问卷收集事件/事故数据，并根据类别和风险级别进行分类。
104 家机构中有 97 家（93.3%）对问卷做出了回应；共报告了 688 起事件/事故。大多数（682 例；99.2%）被归类为风险级别 2；然而，有 6 例属于 3 级及以上，包括自体输血和库存控制问题。约一半的事件/事故（394 例；57.3%）与床边血液制品的验证和实际给药有关；这些事件/事故中超过一半发生在大容量机构。与此同时，在中小规模机构中，观察到与输血检查和血液制品标签相关的事件/事故发生率较高。这些错误的大多数原因是医务人员的简单错误和粗心大意。
尽管电子设备的进步简化了输血程序，但我们的结果强调了对所有医务人员进行教育、操作培训和合规指导的重要性。
