Abstract
The rate of near misses in transfusion is important as it indicates situations with the potential of adverse outcome. The aim of this study was to assess the frequency of mislabeled and miscollected samples received by our transfusion medicine unit. This study was conducted from January to December 2009 in Transfusion Medicine Unit, Hospital Universiti Sains Malaysia. The total number of near-miss events reported and analysed over the 1-year period was 178 (0.40%). All mislabeled and miscollected samples and its location cases were identified. Mislabeled and miscollected (WBIT) samples were 66.3% and 33.7%, respectively. The highest number of mislabeled and miscollected samples was from accident and emergency unit and medical ward, respectively. Continuous monitoring and analysis of near misses data should be mandatory in order to improve the safety of transfusion.
Highlights
Hospital Universiti Sains Malaysia is a teaching hospital in northeastern Malaysia with a total of 800 beds
The laboratory is run by 6 medical technologists, 3 senior medical technologists, 1 scientific officer, and 2 haematologists
Miscollected sample was called wrong blood in tube (WBIT) or defined as samples in which the blood group result was different from the result on the file from the prior testing
Summary
Hospital Universiti Sains Malaysia is a teaching hospital in northeastern Malaysia with a total of 800 beds. The services that are offered by the transfusion medicine laboratory range from routine immunohematology, that is, ABO and Rh grouping, group screen and hold, group cross match, antibody titre and direct Coombs test, to special tests that is, red cell antibody identification, platelet antibody screening, cold agglutinin test, Donath Leinsteiner test, and so forth. We provide peripheral stem cell collection and preparation for the haemato-oncology unit in the hospital. The errors may be preventable, and hospital-wide efforts at prevention are required [1]. Safety and reliability in blood transfusion are not static are dynamic nonevents. Collection of the patient’s sample for pretransfusion testing initiates a complex chain of events in the transfusion process [2]
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