Transfusion monitoring: care practice analysis in a public teaching hospital.

Valesca Nunes Dos Reis,Isabella Bertolin Paixão,Ana Carolina Amaral De São José Perrone Perrone,Kelli Borges Dos Santos,Maria Inês Monteiro

doi:10.1590/s1679-45082016ao3555

Valesca Nunes Dos Reis, Isabella Bertolin Paixão + Show 3 more

Open Access

https://doi.org/10.1590/s1679-45082016ao3555

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Abstract

ABSTRACTObjective To analyze the process of recording transfusion monitoring at a public teaching hospital.Methods A descriptive and retrospective study with a quantitative approach, analyzing the instruments to record transfusion monitoring at a public hospital in a city in the State of Minas Gerais (MG). Data were collected on the correct completion of the instrument, time elapsed from transfusions, records of vital signs, type of blood component more frequently transfused, and hospital unit where transfusion was performed.Results A total of 1,012 records were analyzed, and 53.4% of them had errors in filling in the instruments, 6% of transfusions started after the recommended time, and 9.3% of patients had no vital signs registered.Conclusion Failures were identified in the process of recording transfusion monitoring, and they could result in more adverse events related to the administration of blood components. Planning and implementing strategies to enhance recording and to improve care delivered are challenging.

Highlights

As with a number of therapies, blood transfusion may lead to fatal clinical outcome
To analyze the process of recording transfusion monitoring at a public teaching hospital
A study conducted at hospitals in the United Kingdom (UK) revealed that, despite the fact that most patients (97.7%) received safe transfusions, some were at risk of identification errors and/or of presenting transfusion reaction that would pass unnoticed due to the absence of an identification bracelet, or due to lack of appropriate monitoring during transfusion (2.3%).(12) The present study suggests that there is risk associated with identification error, because patients admitted to the hospital had not been identified with a bracelet

Summary

Introduction

As with a number of therapies, blood transfusion may lead to fatal clinical outcome. constant update and implementation of strategies is essential to reduce or to eliminate inadequate use of blood and blood components. Multidisciplinary transfusion committees, blood surveillance systems, internal and external audit programs, as well as continuing education programs contribute to reducing unnecessary transfusions, enhancing patient safety and improving clinical results.[2,3,4]. In 2012, a total of 3,127,957 blood and blood component transfusions were carried out in public and private health services in Brazil This accounts for an increase by 4.9% as compared to 2011. These severe risks included 188 handling and storage errors, 278 cases of transfusion of the wrong blood component, and 15 deaths.[8]

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Discussion

Conclusion