Transfusion Reported Errors at Siriraj Hospital
Keywords:
Transfusion, Human errors, Blood bank, WardAbstract
Abstract: A policy requiring written report of any significant incidents involving blood transfusion is implemented at Department of Transfusion Medicine, Faculty of Medicine Siraj Hospital, Mahidol University. One of the responsibibies of the Department is to provide blood and blood components for the patients of Siniraj Hospital which has about 2,800 beds. Last year, 25,580 patients required blood transfusion and 64,679 units were crossmatched for them but only 25,745 units were used. During a 20-year period (1979-1998), 188 incident reports involving emors occurred inside and outside of the Department were analyzed. One hundred reported enors (53.2%) occured in the ward. The source of errors were due to taking blood from the wrong patient (37 cases, 37%), giving blood to the wrong patient (19 cases, 19%), placing blood in an unappropriate temperature (24 cases, 24%) and specifying wrong ABO group in blood component order forms (10 case, 10%). Eighty-eight incidents (46.8%) occurred in the blood bank. Among this group, twenty-nine error cases (33%) were related to compatibility testing. The sources of error were using wrong blood sample (14 cases), using wrong ABO blood unit (7 cases) and using outdated blood (1 case) for testing. Another error was due to issuing blood (12 cases, 13 6%) such as issuing blood for another patient (10 cases) and issuing blood of positive viral testing, HBsAg (2 cases). Errors due to issuing blood components (11 cases, 12.5%) were also found in the study. They were issuing blood components with wrong ABO group (8 cases), positive viral testing, HBsAg, VDRL (2 cases) and 1 case of outdated blood component issued. Error in blood collection (10 cases, 11.4%), blood processing (14 cases, 15.9%) and blood components preparation (5 cases, 5.7%) were also reported. In conclusion, it can be seen from the study that the risk of fatal transfusion reactions remains significant. Safe transfusion could be achieved implementation of policies designed to minimize such errots especially in traing and educating all the stalf members who are involved in blood transfusion.
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