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ContextAmong the adverse events in the blood transfusion process, transfusion to a “wrong” patient is potentially dangerous, as it can lead to an adverse reaction at least in case of ABO incompatible red cell concentrate.Material and methodsThe “Root Cause Analysis” working party of the National Hemovigilance Commission developed a tool to collect this type of adverse event, and tested it on a sample of 43 cases involving red cell concentrates notified between March, 2009 and February, 2010.ResultsOne hundred and nine failures of a step in the transfusion process were observed, i.e. 2.5 failures per adverse event. Failures may occur early in the process. However, they are mainly found at the time of issuing of the blood component, and further, in the clinical ward. How the failure is eventually detected is not always described when the blood component has been fully transfused, in contrast with the cases where actual transfusion to the wrong patient has been prevented. Knowing the way of failure detection enables an objective approach of the efficacy of the numerous existing safety measures. In this sample, bedside controls (documents check as well as the use of anti-A and anti-B reagents with patient's blood and red cell concentrates) detected the failure in three cases out of 34, which were not detected before, showing an efficacy similar to the administrative control done at reception in the clinical ward.ConclusionThe document, set up to analyse step by step these cases of patient errors, will be used in the future to analyse all similar cases, not only with red cell concentrates, but also with platelet concentrates and fresh frozen plasma, ultimately in order to improve their prevention.  相似文献   

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Transfusion errors occur at all points in the transfusion chain, often occurring at multiple points in the transfusion process for the same patient. Such events have been reported to national haemovigilance programs in almost all countries, over and over again. An incredible number of safety changes have been implemented to improve blood safety, including but not limited to: nucleic acid testing for HIV/HBV/HCV, bacterial culture for platelet concentrates, use of male-only plasma, and the introduction of pathogen reduction strategies. By contrast, very little momentum has developed behind transfusion safety, in hope of improving the safe delivery of blood to patients. This article will review the interventions that have been studied by transfusion medicine services in attempt to improve transfusion safety at every link in the transfusion chain. The most important and indispensable safety step is the introduction of an error tracking system. Such a system should capture all deviations from standard operating procedures, including near-misses that are captured before the blood product is issued. Near-misses are 300-fold more common and represent latent safety concerns requiring urgent attention. The system should be anonymous to ensure that there is no barrier to reporting and no-fault to recognize that the vast majority of errors are due to latent system errors. The errors should be coded by type and location to allow for the ability to query the error database for the purposes of benchmarking and tracking and trending after system changes. Such a system will allow hospital transfusion services to focus their initiatives at the steps in the transfusion chain most in need of repair at their institution. The system changes that have been studied include: confirmatory group testing, computerized physician order entry, prospective screening of transfusion orders before/after issue, controlled patient registration, regional blood bank information systems, positive patient identification at time of sample collection and the start of transfusion (using barcode or RFID technology), controlled release refrigeration devices, patient involvement in the transfusion process, and healthcare professional education. For each area, the specific technologies or examples will be detailed, the reports from the literature will be reviewed, and the obstacles to implementation will be discussed. Now that blood safety has been assured, we need to re-focus our attentions on the single biggest threat to patients: errors in the transfusion chain at the hospital level. We need to ensure that patients get blood only when required, that they get the correct product of the correct blood group, at the right dose, at the appropriate infusion rate, to the correct patient, at the right time. We need to take a rigorous scientific approach to solving transfusion safety to ensure that each process change is properly tested and validated to verify that each newly introduced process is safe and effective.  相似文献   

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Background Errors occur at all stages of the hospital transfusion process and the resulting morbidity and mortality are well documented. Recent initiatives in the UK and elsewhere to reduce transfusion errors have focussed on implementing recommended manual procedures for good practice, but have only been partially effective. Aims Our approach was to ‘re-engineer’ bedside and laboratory transfusion procedures. Materials and Methods We implemented barcode patient identification, bedside handheld computers and electronically controlled blood fridges to simplify transfusion procedures and improve practice. Results There was an improvement from 11.8% to 100% of staff following the process for correct pre-transfusion bedside patient identification; no ABO incompatible red cell transfusions in 5 years; a reduction in wrong blood component transfused events from 1 in 27,523 to 1 in 67,935; reduced nursing (one nurse rather than 2 and half the time to administer blood) and laboratory workload; and more rapid delivery of urgently required red cell units to patients (from a median of 18 minutes to 45 seconds). The electronic system provided a simple mechanism for compliance with UK/EU regulatory requirements for the traceability of blood, and the documentation of transfusion and training. Feedback from both staff and patients was positive. Discussion The project was taken through pilot stages between 2001 and 2006 through to its full implementation across the acute hospitals in Oxfordshire in 2006/07. Our group wrote a national specification for the electronic transfusion process, but the implementation elsewhere in the UK has been slow. There is the potential to introduce an additional module into the electronic transfusion process to provide ‘decision support’ for doctors ordering blood to minimise inappropriate use of blood as part of a patient blood management programme, and use the same ‘end-to-end electronic’ approach for other clinical procedures such as drug administration. Conclusion The implementation of a hospital electronic transfusion management system was shown to provide improvement in transfusion practice and in the efficiency of the service.  相似文献   

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The Serious Hazards of Transfusion (SHOT) scheme has now accumulated 8 years' data. The most frequently occurring adverse event, accounting for 1832/2628 (70%) of incidents reported, is 'incorrect blood component transfused' (IBCT) in which the patient receives a blood component that did not meet the correct specification or that was intended for another patient. Errors can occur at all stages of the transfusion chain and, in about half of cases, multiple system failures can be identified. Analysis of 130 ABO incompatible transfusions reported between 1999 and 2003 identified 221 separate errors, 68% of which took place in clinical areas and 29% in hospital laboratories. The commonest single error is failure to check at the bedside that the right blood is being given to the right patient. Certain patients, e.g. neonates, those transfused at night and in critical care situations, appear to be particularly vulnerable. It is encouraging that, against a background of ever increasing numbers year-on-year of reports of IBCT, the incidence of ABO incompatible transfusions already shows a downward trend, suggesting the emergence of a safety culture.  相似文献   

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Haemovigilance, an important step in transfusion safety, had been set up by a French law in January 1993. Application of haemovigilance in public hospitals is based on three conditions: reporting of adverse transfusion events, traceability of blood products and prevention of adverse transfusion events. The implementation of haemovigilance follows the rules given in a Ministry order dated January 1994, the first of a series including regulations about patient information, virological follow-up of transfused patients, blood product distribution. Haemovigilance rules are the same for adults as for children, concerning blood product traceability and adverse event reporting. It is much more difficult in other fields such as autologous transfusion and "child-patient" information that depend on their parent advice and should be particularly adapted to the familial context, the type of disease and the treatment. Difficulties arise for completing pre- and post-transfusion, immuno-haematologic and virologic controls. Compliance to protocols, in agreement with blood banks, is necessary.  相似文献   

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STUDY OBJECTIVES: To quantify the prevalence of self-reported near-miss sleepy driving accidents and their association with self-reported actual driving accidents. DESIGN: A prospective cross-sectional internet-linked survey on driving behaviors. SETTING: Dateline NBC News website. RESULTS: Results are given on 35,217 (88% of sample) individuals with a mean age of 37.2 +/- 13 years, 54.8% women, and 87% white. The risk of at least one accident increased monotonically from 23.2% if there were no near-miss sleepy accidents to 44.5% if there were > or = 4 near-miss sleepy accidents (P < 0.0001). After covariate adjustments, subjects who reported at least one near-miss sleepy accident were 1.13 (95% CI, 1.10 to 1.16) times as likely to have reported at least one actual accident as subjects reporting no near-miss sleepy accidents (P < 0.0001). The odds of reporting at least one actual accident in those reporting > or = 4 near-miss sleepy accidents as compared to those reporting no near-miss sleepy accidents was 1.87 (95% CI, 1.64 to 2.14). Furthermore, after adjustments, the summary Epworth Sleepiness Scale (ESS) score had an independent association with having a near-miss or actual accident. An increase of 1 unit of ESS was associated with a covariate adjusted 4.4% increase of having at least one accident (P < 0.0001). CONCLUSION: A statistically significant dose-response was seen between the numbers of self-reported sleepy near-miss accidents and an actual accident. These findings suggest that sleepy near-misses may be dangerous precursors to an actual accident.  相似文献   

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Blood transfusion is an integral component of the health Service system and it becomes imperative that its benefits, risks as well as prospective and viable alternatives of this common medical intervention are explained explicitly to the patients. Appropriate compliance to bedside blood transfusion practices can also help in avoiding adverse transfusion outcomes. At the same time, it is also crucial to document a patient's valid consent based on their decision after evaluation of the risk to benefit ratio. This audit aims to assess the compliance and adherence to bedside blood transfusion practices in a tertiary care hospital and role of Continuous Medical education (CME) on it. The study involved collection of data for blood transfusion services and practices in two periods, for adults and children, who received transfusion from the month of June 2021 to October 2021 and a re-audit beginning from November 2021 to February 2022 following few CMEs in between involving doctors and nurses. A total of 3240 transfusion procedures were assessed in this duration. In them 1500 (46.3%) took place before CME and remaining 1740 (53.7%) procedures took place after CME. There were statistically significant differences between pre-CME and post-CME bedside transfusion practices. During CME/training session, pre-training and post training knowledge has been evaluated by test which also showed statistically significant difference in knowledge of transfusion medicine & bedside transfusion practices. Our study recommends that there is a need of frequent audit on bedside transfusion practices to check the quality and standards associated with it and also points out the need of continuous medical education on this issue.  相似文献   

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Blood transfusion is an important component of modern day medicine. As doctors our first consideration must always be the interests and safety of our patients. Haemovigilance programmes collect and analyse data on untoward events associated with transfusion. The information collated should be shared with health professionals who prescribe and administer blood products so that they can continue to deliver the good without unintended negative consequences. The European Directorate for the Quality of Medicines and Healthcare (EQDM) defines the standards for haemovigilance and acknowledges that it is a shared responsibility of the professionals in the field and the competent national authorities for blood safety. It includes the surveillance of donor-related events, epidemiological assessment of infections in donors, full traceability of blood components, device defects and reporting of post-transfusion infections. Implementation of a national haemovigilance system is a complex task and usually takes months of planning. Apart from the multiple resources it requires, a number of issues need to be considered: what is to be reported, how will it be reported and who will do the reporting. In addition, information and training needs to be provided to the key stakeholders. In order for a haemovigilance programme to be effective the data need to be collated, analysed and relayed back to the hospitals. Comprehensive annual haemovigilance reports that are readily accessible can include recommendations to promote strategies to reduce transfusion-related risks. In New Zealand the National Haemovigilance Programme was established in 2005. The population of New Zealand is 4·1 million. Reporting is voluntary and usually mediated via the hospital blood banks. The larger hospitals have Transfusion Nurse Specialists (TNSs) who provide education and assist with reporting adverse events. New Zealand is a country member of the Internal Haemovigilance Network (IHN) and utilizes the definitions of reporting categories agreed upon by the IHN. The majority of reports involve reactions that are mild. The overall rate of an adverse event is approximately 1 in 300 units transfused. Platelet concentrates are more frequently associated with reactions compared with other blood components and reactions are predominantly of the allergic type. The Haemovigilance Programme has demonstrated a reduction in the reported rate of transfusion-related acute lung injury (TRALI) since the introduction of male donor fresh frozen plasma (FFP) 3 years ago. The programme has also identified that bacterial contamination of blood components, incorrect blood component transfused (IBCT), wrong blood in tube (WBIT) and acute haemolytic transfusion reactions due to transfusion of passive haemolysin are risks that require further attention. Complications associated with blood donation are also included in the annual haemovigilance reports. Vasovagal reactions are the most frequently occurring donation-associated event and are higher in donors under the age of 20 years. Ongoing surveillance and review of untoward events associated with transfusion is vital so that we can continue to minimize risks related to blood products.  相似文献   

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ABO incompatible transfusions are still a frequent cause of serious adverse transfusion reactions. Bedside check is intended to detect patient errors and prevent ABO mismatch. France is one of the few countries that includes ABO agglutination test for red blood cells in bedside checks. Evaluation of this ABO agglutination test, performed with a special card, shows that, on the field, despite frequent users’ mishandling, it can detect up to 93% of ABO incompatibilities. This is not enough to rely on this sole test for bedside checks. But, linking it with an another test, currently, checks that the right blood is given to the right patient, rises the sensitivity of the whole bedside procedure up to an estimated 99.65%, for detection of ABO incompatibilities. This linkage has been introduced in the French regulation in 2003. Since then, the incidence of ABO incompatible transfusions has decreased dramatically and faster than in any other country, so France has now, probably, the lowest rate of ABO incompatible transfusions. The investigation of the few ABO accidents that still occur, shows that professionals have always bypassed this linkage. On the other hand, introducing bedside recipient and blood products barcode or radio-chip checks in all the 1500 French hospitals, though technically possible, would provide very little enhancement and lead to major difficulties and expenses. Linkage of ABO agglutination test to patient and blood checks within the bedside procedure has proved to be efficient and should be kept.  相似文献   

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Cox LM  Logio LS 《Academic medicine》2011,86(11):1473-1478
Incident reports have traditionally been the vehicle for identifying, assessing, and responding to quality gaps in hospitals. Yet because of a variety of barriers, residents often fail to participate in this formal process. The authors created a project to engage residents in incident reporting through the use of an online, anonymous narrative format, faculty-facilitated discussion groups, and involvement of patient safety officers in the educational process. During three months, 36 residents submitted a total of 79 stories about patient care that did not "go as intended." The authors reviewed and scored each story for contributing factors and outcomes. The residents met monthly in small groups with trained faculty facilitators to analyze the stories, which were also shared with the patient safety officers. The stories, narratives of both personal involvement and observed events, ranged from near-misses to sentinel events. Key contributing factors included lapses of professionalism, decision errors, communication/information mishaps, transition mix-ups, and workload difficulties. The narrative format proved a feasible tool for collecting significant, previously unrecognized patient safety issues. Internal medicine residents were willing to discuss gaps in care when given the tools and opportunity for anonymous storytelling and blame-free dialogue.  相似文献   

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OBJECTIVES:

The World Health Organization has recommended investigating near-misses as a benchmark practice for monitoring maternal healthcare and has standardized the criteria for diagnosis. We aimed to study maternal morbidity and mortality among women admitted to a general intensive care unit during pregnancy or in the postpartum period, using the new World Health Organization criteria.

METHODS:

In a cross-sectional study, 158 cases of severe maternal morbidity were classified according to their outcomes: death, maternal near-miss, and potentially life-threatening conditions. The health indicators for obstetrical care were calculated. A bivariate analysis was performed using the Chi-square test with Yate''s correction or Fisher''s exact test. A multiple regression analysis was used to calculate the crude and adjusted odds ratios, together with their respective 95% confidence intervals.

RESULTS:

Among the 158 admissions, 5 deaths, 43 cases of maternal near-miss, and 110 cases of potentially life-threatening conditions occurred. The near-miss rate was 4.4 cases per 1,000 live births. The near-miss/death ratio was 8.6 near-misses for each maternal death, and the overall mortality index was 10.4%. Hypertensive syndromes were the main cause of admission (67.7% of the cases, 107/158); however, hemorrhage, mainly due to uterine atony and ectopic pregnancy complications, was the main cause of maternal near-misses and deaths (17/43 cases of near-miss and 2/5 deaths).

CONCLUSIONS:

Hypertension was the main cause of admission and of potentially life-threatening conditions; however, hemorrhage was the main cause of maternal near-misses and deaths at this institution, suggesting that delays may occur in implementing appropriate obstetrical care.  相似文献   

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Event reporting can provide data to study the failure points of an organization's work process. As part of the ongoing efforts to improve transfusion safety, a Medical Event Reporting System Transfusion Medicine, (MERS - TM) as designed by Kaplan et al was implemented in the Transfusion Medicine Unit of the University Malaya Medical Centre to provide a standardized means of organized data collection and analysis of transfusion errors, adverse events and near misses. An event reporting form was designed to detect, identify, classify and study the frequency and pattern of events occurring in the unit. Events detected were classified according to Eihdhoven Classification model (ECM) adopted for MERS - TM. Since our system reported all events, we called it Event Reporting System - Transfusion Medicine (ERS-TM). Data was collected and analyzed from the reporting forms for a period of five months from January 15th to June 15th 2002. The initial half of the period was a process of evaluation during which 118 events were reported, coded, analyzed and corrective measures adopted to prevent the recurrence of the same event. The latter half saw the reporting of 122 events following the adoption of corrective measures. There was a reduction in the occurrence of some events and an increase in others, which were mainly beyond the organization's control. A longer period of evaluation is necessary to identify the underlying contributory causes that can be useful to develop plans for corrective and preventive action and thereby reduce the rate of recurrence of errors through proper training and adoption of just culture.  相似文献   

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Even with the great progress in blood safety, such as the nucleic acid amplification test(NAT) for HBV, HCV and HIV, ABO-mismatched transfusion still occurs in the 21st century. Computer crossmatch between the patient's blood type already registered on computer, the patient's blood type as examined just before transfusion and the blood type labeled on blood bags all help avoid misunderstanding of blood type at shipping. Computerized management of the transfusion services database is also effective in promoting appropriate transfusion or autologous transfusion. Since mistakes can occur anywhere in the system, the Japanese Society of Blood Transfusion(JSBT) made a poster showing six steps where errors were most likely. They then distributed a questionnaire about mismatched transfusion to 777 major hospitals and made it clear that the main cause of mistakes was confirmation errors at bedside before transfusion. In response to the findings, JSBT created a manual for performing exactly matched and safe transfusions, including a manual for transfusion in emergencies, as well as first-line treatment procedures in case of major mismatched transfusion. In order to avoid mistakes at bedside, a barcode matching system between the patient's wristband and blood bag is ideal. It will also be useful for comprehensive risk management in modern medicine.  相似文献   

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The report of the Institute of Medicine (IOM) To Err is Human recommended that both mandatory and voluntary event-reporting systems be established to identify and learn from errors. Because of the tight coupling of graduate medical education (GME) programs and the delivery of care, any event-reporting system used in a teaching hospital should be able to document the types of errors that are being made by graduate medical trainees (GTs). The authors performed an analysis of the root causes of events involving GTs that were recorded in hospital-based near-miss reporting systems. The root causes were classified using the Eindhoven Classification Model, medical version. Case histories of three separate events, one from an accident and emergency department in the United Kingdom, and two from a large teaching hospital in the United States, are used to illustrate the method. In all three cases, lack of knowledge on the part of the trainee contributed to the incident. Inadequate educational preparation had the potential for causing significant harm to the patient. Organizational causes were also present in each case, which illustrates the need to examine not only educational issues but also procedural and management issues related to GME. In each case, the analysis revealed in striking clarity deficiencies of educational content and problems of program structure. The authors conclude that doing a root-cause analysis in conjunction with a near-miss event-reporting system in a teaching hospital can be a valuable source of documented information to guide needed educational and system changes to GME programs.  相似文献   

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If a patient has no clinically significant unexpected antibodies, a major crossmatch is not required prior to blood transfusion so long as a test method that demonstrates ABO incompatibility is done. In this study, the safety of using a noncrossmatch method for detecting ABO incompatibility was compared with the use of an immediate spin crossmatch (ISCX). This noncrossmatch method consisted of the duplicate ABO testing of blood recipients, the repeated ABO testing of donor blood, and a clerical check to assure that only ABO matched or compatible blood was selected for transfusion. During the one-year study, 7124 patient samples were tested in duplicate for ABO, 26,942 U of red blood cells received from blood collection facilities were retested for ABO, and 23,962 U of blood selected for transfusion based on the noncrossmatch method were tested by an ISCX. ABO test results were concordant for 7115 of 7124 patient samples and discordant for nine. Seven of the nine discordant patient test results were resolved prior to transfusion, and two were inadvertently overlooked. ABO test results were concordant for 26,922 of 26,942 donor units and discordant for 20. Seventeen of the 20 discordant donor test results were resolved prior to transfusion and three were inadvertently overlooked. Two ABO incompatibilities were missed by the noncrossmatch method but were detected by the ISCX. Unless clerical errors can be totally eliminated, it may be safer to retain the ISCX.  相似文献   

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The advent of leukocyte filters has enabled effective removal of leukocytes from certain blood products thus avoiding many adverse effects of blood transfusion. Many different materials have been incorporated into these filters to achieve >95% leukocyte removal. In this study we evaluated the efficacy of leukocyte removal of two different filters, using actual bedside transfusion settings involving patients with transfusion dependent thalassaemia. Fifty-one transfusion events were randomised to use either a polyurethane filter or a non-woven polyester filter. We found that the two filters achieved 98.4% and 96.2% leukocyte removal respectively (p = 0.022). We also found no significant correlation between pre-filtration white blood cell count and the volume transfused with the efficacy of leukodepletion. No untoward events or transfusion reactions were observed during the study.  相似文献   

19.
The Imugard IG 500 cotton wool filter and the Cellselect cellulose acetate filter were adapted for filtration of leucocytes from packed cell transfusions at the bedside. Sixty five transfusions were given via the Imugard IG 500 filter and 54 transfusions were given via the Cellselect filter. Packed red cell concentrates from the National Blood Transfusion Service provided for routine blood transfusions were used in all cases. No patient in either group of multitransfused patients experienced a febrile blood transfusion reaction during the study. The Imugard IG 500 removed 91% +/- 9 (SEM) leucocytes; the Cellselect removed 96% +/- 7 (SEM) leucocytes. In the Imugard IG 500 group one patient received greater than 0.5 X 10(9) leucocytes. In the Imugard IG 500 group one patient received greater than 0.5 X 10(9) leucocytes, but no patient in the Cellselect group received greater than 0.5 X 10(9) leucocytes in any single transfusion. This is a safe method of providing leucocyte poor blood at the bedside.  相似文献   

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The key to error reduction in medicine is to focus on the process being applied and not just those performing the process. As human error is inevitable, it is necessary to evaluate and re‐design processes so that errors cannot happen or are reliably detected and interdicted before patient harm is the outcome. One tool that is useful to ensure that a process has been completed correctly is a ‘process control’, a step in a process the successful completion of which ensures that all preceding critical steps have been accomplished successfully. (An example from immunohematology is the use of ‘check cells’.) To reduce the risk of mistransfusion, for example, process controls can be applied by using bedside systems that apply to the patient's bar‐coded identification to the label of a pretransfusion testing sample or by using a mechanical barrier system to ensure that the person who gave that sample is the one receiving the transfusion. Other approaches include the use of remote‐release refrigeration systems or the use of only Group O red cells for transfusion until the patient's ABO group has been confirmed on a second sample. Applying techniques like this would significantly reduce the ongoing – but avoidable – catastrophes of acute hemolytic transfusion reactions.  相似文献   

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