Mercuriali F, Inghilleri G, Colotti M T, Farè M, Biffi E, Vinci A, Podico M, Scalamogna R
Centro Trasfusionale e di Immunoematologia, Instituto Ortopedico G. Pini, Milano, Italy.
Vox Sang. 1996;70(1):16-20. doi: 10.1111/j.1423-0410.1996.tb00990.x.
Clerical errors occurring during specimen collection, issue and transfusion of blood are the most common cause of AB0 incompatible transfusions. 40-50% of the transfusion fatalities result from errors in properly identifying the patient or the blood components. The frequency and type of errors observed, despite the implementation of measures to prevent them, suggests that errors are inevitable unless major changes in procedures are adopted. A fail-safe system, which physically prevents the possibility of error, was adopted in January 1993 and concurrently a quality improvement program was implemented to monitor any transfusion errors. Up to December 1994, 10,995 blood units (5,057 autologous and 5,938 allogeneic) were transfused to 3,231 patients. Seventy-one methodological errors(1/155 units) were observed, half of which were concentrated during the first 4 months of introducing the system. However the system detected and avoided four potentially fatal errors (1/2,748 units). Two cases involved the interchanging of recipient sample tubes, 1 case was due to patient misidentification and the other involved misidentification of blood units. In conclusion the system is effective in detecting otherwise undiscovered errors in transfusion practice and can prevent potential transfusion-associated fatalities caused by misidentification of blood units or recipients.
标本采集、发放及输血过程中发生的文书错误是ABO血型不相容输血最常见的原因。40%-50%的输血死亡是由患者或血液成分识别错误导致的。尽管采取了预防措施，但观察到的错误频率和类型表明，除非对程序进行重大改变，否则错误是不可避免的。1993年1月采用了一种能切实防止出错可能性的故障安全系统，同时实施了一项质量改进计划，以监测任何输血错误。截至1994年12月，共向3231名患者输注了10995个单位的血液（5057个自体单位和5938个异体单位）。观察到71例方法错误（1/155单位），其中一半集中在引入该系统的前4个月。然而，该系统检测并避免了4例潜在的致命错误（1/2748单位）。2例涉及受血者样本管互换，1例是由于患者身份识别错误，另1例涉及血液单位识别错误。总之，该系统能有效检测输血操作中原本未被发现的错误，并可预防因血液单位或受血者识别错误导致的潜在输血相关死亡。
