Nitsche Elisabeth, Dreßler Jan, Henschler Reinhard
Department of Forensic Medicine, Institute of Legal Medicine, University of Leipzig, Leipzig, Saxony, Germany.
Department of Quality Control, Institute of Transfusion Medicine, University Hospital Leipzig, Leipzig, Saxony, Germany.
J Blood Med. 2023 Aug 8;14:435-443. doi: 10.2147/JBM.S411188. eCollection 2023.
Reporting of transfusion reactions is good practice and required by many guidelines. Errors in the transfusion chain can also lead to severe patient reactions and depend on active error reporting. We aimed to characterize transfusion incidents and asked whether workup of transfusion reactions may also contribute to revealing logistical errors.
Transfusion medical records from 2011 to 2019 at our tertiary medical centre, as well as forensic autopsy reports, digitized sections, and court records from 1990 to 2019 were analysed. A total of 230,845 components were transfused between 2011 and 2019 at our own institution.
Overall, 322 transfusion incidents were reported. Of these, 279 were from our own institution, corresponding to a frequency of 0.12% of all transfusions. The distribution of reaction types is consistent with the literature, with allergic reactions (55.9%), febrile-non-hemolytic reactions (FNHTR, 24.2%), hemolytic reactions (3.4%) and other types at smaller frequencies (<3%). Twenty-nine (10.4%) of the 279 reports revealed logistical errors, including hemoglobin above guideline threshold (4.3%), incorrect or non-performed bedside tests (3.2%), inadequate patient identification (2.5%), laboratory and issuing errors, missed product checks or failure to follow recommendations (1.1% each). Eight of 29 (27.5%) of the logistical errors were detected by serendipity during workup of incident reports. In addition, 8/932 autopsy cases under code A14 (medical treatment errors) were found to be transfusion-associated (0.9%).
Systematic workup of transfusion incidents can identify previously undetected errors in the transfusion chain. Passive reporting of errors through the recording of side effects may serve as a tool to assess more closely assess the frequency and quality of handling errors in real life, and thus serve to improve patient safety.
报告输血反应是良好的做法，也是许多指南所要求的。输血链中的错误也可能导致严重的患者反应，这依赖于主动的错误报告。我们旨在描述输血事件的特征，并询问对输血反应的检查是否也有助于发现后勤错误。
分析了我们三级医疗中心2011年至2019年的输血医疗记录，以及1990年至2019年的法医尸检报告、数字化切片和法庭记录。2011年至2019年期间，我们自己的机构共输注了230,845个血液成分。
总体而言，共报告了322起输血事件。其中，279起来自我们自己的机构，占所有输血的0.12%。反应类型的分布与文献一致，过敏反应（55.9%）、发热非溶血性反应（FNHTR，24.2%）、溶血性反应（3.4%）以及其他类型（频率较低，<3%）。279份报告中有29份（10.4%）显示存在后勤错误，包括血红蛋白高于指南阈值（4.3%）、不正确或未进行床边检查（3.2%）、患者识别不足（2.5%）、实验室和发放错误、遗漏产品检查或未遵循建议（各1.1%）。29起后勤错误中有8起（27.5%）是在事件报告检查过程中偶然发现的。此外，在代码A14（医疗差错）下的932例尸检病例中，有8例（0.9%）被发现与输血相关。
对输血事件进行系统检查可以识别输血链中以前未被发现的错误。通过记录副作用对错误进行被动报告，可作为一种工具，更密切地评估现实生活中处理错误的频率和质量，从而有助于提高患者安全。
