Noor Noor Haslina Mohd, Joibe Kimberly Fe, Hasan Mohd Nazri
School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia.
Transfusion Medicine Unit, Hospital Universiti Sains Malaysia, Kelantan, Malaysia.
Oman Med J. 2021 Mar 31;36(2):e249. doi: 10.5001/omj.2021.55. eCollection 2021 Mar.
A near miss in transfusion practice is defined as a deviation from standard procedures discovered before transfusion and can lead to a transfusion error. Information on near-miss events provides pivotal data on areas of improvement to prevent actual errors in the future. Our study sought to determine the prevalence and rate of near-miss events and their associated factors amongst house officers (HO) in Hospital Universiti Sains Malaysia.
The initial part of this study is a descriptive cross-sectional study involving data collection from all requests sent for group, screen, and hold (GSH) and group and cross match (GXM) tests from 2011 to 2017. The association between sociodemographic, workplace, and experience factors with near-miss events amongst HO was analyzed with a case-control study using logistic regression.
We reported 83 near-miss events with a prevalence of 0.034% (95% confidence interval 0.027-0.042). The rate of near-miss events was one in every 2916 requests. The mean reporting rate was 11.9 events per year. Clinical near miss predominated at 89.2% compared to 10.8% laboratory near miss. Mislabeled events (33.7%) were more than miscollected events (10.8%). HO were implicated with most events (83.1%). Most events were predominantly in the medical and obstetrics and gynecology wards amounting to 31.3% each. We found a significant association between the ages of HO with near-miss events.
The prevalence of near-miss events in our hospital was relatively low. Our study has shown areas for improvement include improving sampling practices in clinical areas, adequate training of laboratory technicians, and providing proper transfusion education. Interventions such as encouraging compliance to guidelines and training in clinical and laboratory areas to minimize the risk of mistransfusion should be considered.
输血操作中的险些失误被定义为在输血前发现的与标准程序的偏差，可能导致输血错误。险些失误事件的信息为未来预防实际错误的改进领域提供了关键数据。我们的研究旨在确定马来西亚理科大学医院住院医师中险些失误事件的发生率、发生率及其相关因素。
本研究的初始部分是一项描述性横断面研究，涉及收集2011年至2017年所有送检的血型鉴定、筛查和保存（GSH）以及血型鉴定和交叉配血（GXM）检测请求的数据。采用病例对照研究和逻辑回归分析住院医师的社会人口统计学、工作场所和经验因素与险些失误事件之间的关联。
我们报告了83起险些失误事件，发生率为0.034%（95%置信区间0.027 - 0.042）。险些失误事件的发生率为每2916次请求中发生1次。平均报告率为每年11.9起事件。临床险些失误占主导，为89.2%，而实验室险些失误为10.8%。标签错误事件（33.7%）多于标本采集错误事件（10.8%）。大多数事件涉及住院医师（83.1%）。大多数事件主要发生在内科以及妇产科病房，各占31.3%。我们发现住院医师年龄与险些失误事件之间存在显著关联。
我院险些失误事件的发生率相对较低。我们的研究表明，改进领域包括改善临床区域的采样操作、对实验室技术人员进行充分培训以及提供适当的输血教育。应考虑采取干预措施，如鼓励遵守指南以及在临床和实验室领域进行培训，以尽量减少输血错误的风险。
