Abstract
Although Canada has one of the safest blood systems in the world, transfusion errors can occur at any time from the moment of collection through to the transfusion of blood and blood products. The Transfusion Error Surveillance System (TESS) was initiated by the Public Health Agency of Canada (the Agency) to monitor transfusion-related errors occurring at any point in the transfusion chain. To offer an analysis of the TESS data reported from 2008 to 2011. Between 2008 and 2011, 12 to 15 hospitals from four provinces participated in the TESS. Reports on all transfusion-related errors were sent electronically on a quarterly basis to the Agency where they were consolidated, cleaned, validated and analyzed. Different types of transfusion errors were categorized by time of discovery (pre- or post-transfusion) and their potential impact on the patient's health. The occurrence rates of different types of errors were calculated using corresponding denominator data. Results were grouped by the transfusion capacity of reporting hospitals. Between 2008 and 2011, a total of 34,088 transfusion-related errors were reported. Of these, 33,622 (98.6%) were detected prior to transfusion. The most commonly reported were errors related to the collection (40.1%) and handling (10.4%) of blood samples. Of the remaining 466 (1.4%) that were detected after transfusion, 66 were of high potential severity and 16 of them resulted in adverse reactions in recipients. Inappropriate / incorrect / no product order accounted for over 56% (n=9) of these errors and the most common adverse reaction was transfusion-associated circulatory overload which occurred in eight (50%) of the patients that developed adverse reactions. The TESS data from 2008 to 2011 demonstrates that blood transfusions are both safe and efficient in Canadian hospitals participating in the surveillance and also highlights the most common and most harmful errors that may be targeted for corrective actions.
Highlights
Blood transfusions are one of the key components of Canada’s healthcare system
The most commonly reported were errors related to the collection (40.1%) and handling (10.4%) of blood samples
Of the remaining 466 (1.4%) that were detected after transfusion, 66 were of high potential severity and 16 of them resulted in adverse reactions in recipients
Summary
Blood transfusions are one of the key components of Canada’s healthcare system. Each year in Canada, blood transfusions are used to treat people suffering from blood loss, anemia and cancer. Errors that can occur along the blood transfusion chain either before or after the actual transfusion may result in blood type (ABO) incompatibilities, administrative delays, product wastage and even inappropriate transfusions. These errors have the potential to impact patient safety and increase costs incurred by the healthcare system. Outputs of the TESS are valuable at more than one level as they identify where and when most high potential severity errors occur in the transfusion chain, they provide a benchmark for national and international comparisons Most importantly, they assist in the development and assessment of transfusion safety measures. The Transfusion Error Surveillance System (TESS) was initiated by the Public Health Agency of Canada (the Agency) to monitor transfusion-related errors occurring at any point in the transfusion chain
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