Adverse Effects of Blood Transfusion and Transfusion Errors at Police General Hospital

บทคัดย่อ

Abstract:

Background: A policy of Risk Management Committee (RMC) of Police General Hospital
has  declared that blood bank has to submit the incidence report of transfusion errors and adverse effects
of blood transfusion. These data have been analyzed in order to improve the safety of blood transfusion.
Methods: A retrospective review of transfusion errors and transfusion reactions during a  5-year period
(2001-2005) was analyzed and divided into the following categories: the cause and source  of errors,
typed of blood components transfused with sign and symptom of transfusion reactions. Results: Four
hundred and nineteen errors have been reported that: 60 errors (14.3%) occurred in blood bank,  359 errors
(85.7%)  occurred in clinical areas. These errors led to 7 wrong blood transfusions (2 wrong  patient
transfusions,  2 incorrect blood groupings and 2 wrong blood samplings). There were 5  in 7 patients
received  ABO-incompatible blood (1 incompatible red cell transfusion and 4 incompatible FFP transfusions)
 but no death was reported. The incidence of adverse effects of blood transfusion was found
in  226 reports (0.34%). The highest proportion of these reactions was due to urticaria (62.8%) and followed
 by FNHTR (32.3%). Blood components which caused most reactions were 133 units of PRC
(58.8%) and 75 units of FFP (33.2%). Conclusion Though the incidence of ABO-incompatible blood
transfusion is low, it can cause serious morbidity and mortality. These errors must be reduced and
eliminated by having a system of transfusion audit, training and educating all staff who are involved
in blood transfusion system. The majority of transfusion reactions (urticaria and FNHTR) can be reduced
 and prevented by using leukocyte depleted blood or leukocyte poor blood and pre-transfusion
medication  with antipyretics and antihistamine. The benefit of this report can be used to improve the
safety  for blood transfusion system.