An Audit on Transfusion error in 16 years of blood transfusion practice at a Teaching Hospital in North Eastern Malaysia

Abstract

Clinical demand for blood transfusion is endless, and patients are exposed to the risk of transfusion error at any point along the transfusion chain which lead to incorrect blood component transfused (IBCT) if the standard transfusion practices have not complied. This study aimed to determine the prevalence, sources, and causes of error among IBCT in Hospital USM. This retrospective study involved all packed red cell (PC) transfusion and reported IBCT in Transfusion Medicine Units, Hospital USM from January 2005 to December 2020. The recipient and transfusion data of IBCT were collected from the medical record and laboratory information system (MyTransfusi). A total of 193 697 PC transfusions were documented, and 14 IBCT were reported within 16 years of transfusion services. The incidence of IBCT was 1 in 13 836 of PC transfusion. Most of the IBCT contributed by ward error (64.3%). The major cause of error was patient miss identification (85.7%) either in patient sampling, blood component issuing and administration. Most ABO incompatibility IBCT (3 out of 5) end up with severe morbidity or mortality related to an acute haemolytic transfusion reaction. Most of the errors occurred in the wards. Patient misidentification is a major cause of IBCT, and it is preventable. Thus, preventive measures should emphasize on positive patient identification at every step of transfusion chain.