near-misses in sample collection and in blood component ... · near-misses in sample collection and...
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Near-misses in sample collection and in bloodcomponent transfusion. An incidence study
using an electronic transfusion safety system
1
Dr. José-Luis Bueno Hematology and Hemotherapy Department
Hospital Universitario Puerta de Hierro Majadahonda (Madrid)
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Conflict of Interest Disclosure
• Grifols– Consultancy
– Honoraria
• Janssen– Consultancy
– Honoraria
• PRoPosit– CEO
– Medical Director
• Sanofi– Consultancy– Honoraria– Medical writting– Advisory Committees
• Onega+– Consultancy
I hereby declare the following potential conflicts of interest concerning
my presentation:
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4
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Errors ocurring during transfusion
of a blood component
ABO incompatible
transfusion
Death as result of an incorrect
blood component transfusion
5
• SHOT 1996-2003
• Risk of an error ocurring during transfusion of a blood component 1:16.500
• Risk of an ABO incompatible transfusion 1:100.000
• Risk of a death as result of an incorrect blood component transfusion 1:1.500.000
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Transfusion with unknown donor and recipentABO typing, in caucasian matchs in around 63%
A NEG, 6.83%
A POS, 36.80%
AB NEG, 0.55%
AB POS, 3.20%
B NEG, 1.29%B POS, 8.25%
O NEG, 6.26%
O POS, 36.82%
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1 ABO Hemolitic Transfusion reaction
Near-misses
2 asintomatic ABO errors
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10136
12172
13897
1508114610
12914 1316013690
1443613461
4138 4543 4141 4466 46933348 3556
3494
36472516
13461906
2718 2962 27982259
3211
2943 2798 2929
0
2000
4000
6000
8000
10000
12000
14000
16000
year2008
year2009
year2010
year2011
year2012
year2013
year2014
year2015
year2016
year2017
Puerta de Hierro-Majadahonda Hospital. Transfusions 2008-2017
RBCs
Plasma units
Platelet units
-7,3
20.881 18.906
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Blood sample verification. Before 2013
Second blood sample
collection in new patient
ABO Rh checking against
previous record
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Blood sample verification. Before 2013
Second blood sample collection in new patient
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Bed-side verification. Before 2013
“Wet test” blood group checking in the bedside
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Bed-side verification. Before 2013
“Wet test” blood group checking in the bedside
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13
135 events/ 123941 transfusions
10,9 events/ 10.000 transfusions
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Hemovigilance between 2010 y 2012 HUPHM
RBC % PLT % FFP % Total
HTR (ABO) 4 0,9 0 0,0 0 0,0 4 0,6
Febrile or hypotensive non hemolytic 37 8,5 4 4,7 1 0,8 42 6,4
Allergic 5 1,1 3 3,5 25 18,8 33 5,0
TRALI/TACO 0 0,0 0 0,0 0 0,0 0 0,0
Bacterial Contamination 1 0,2 0 0,0 0 0,0 1 0,2
Near miss 1 0,2 0 0,0 0 0,0 2 0,3
Total 4811,
0 7 8,3 26 19,5 81 12,4
Units transfused4358
8 8478 13300 65366
By 10.000 11,0 8,3 19,5 12,4
Haemovigilance Report 2010-2012
14
1 ABO error per 11.000 units transfused
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ERRORS
Near-misses
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Blood sample verification
16
Blood-Bank verification
Bed-side patient and blood
component checking
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USERDATE TIME WARD BLOOD COMPT. CORRECT?PATIENT
Gricode web based software
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Objective
Define the incidence of near-misses in thesample collection and in the blood componentstransfusion using our electronic safety system
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Methods
• Observational, retrospective, one-center study
• Near-misses incidence in sample collection and blood components transfusion
• Years 2014-2017
• Analysis by year, time, nurse shift, ward, operator
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Near-misses in SC & BCT 2014-2017
Number of checkingsperformed
Missmatches(Near-misses)
Near-missespercent
Blood samplecollections
55.636 1.995 3,59%
Beginning of transfusions
81.168* 548 0,67%
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Blood sample collection
21
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3.05%
2.21%2.58% 2.53%
6.88%
8.09%
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
8.00%
9.00%
2013 2014 2015 2016 2017 2018
Blood sample collection near-misses,
per year
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0001- 713 22 3,09%
0002- 1041 72 6,92%
0003- 41 4 9,76%
0004- 1006 37 3,68%
0005- 1709 70 4,10%
0006- 5311 59 1,11%
0010- 11380 446 3,92%
0011- 1109 66 5,95%
0012- 1279 60 4,69%
0013- 338 49 14,50%
0014- 388 18 4,64%
HDD Qx 8340 61 0,73%
Blood sample collection near-misses per ward2014-2017
Ward Checkings Miss-matches Miss-matches %
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0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Miss-matches percent per hour
0
2000
4000
6000
8000
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Sample collections per hour, number
Blood sample collection near-misses per hour and nurse shift2014-2017
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25
Beginning of transfusion
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2.74%
0.70% 0.64%
0.40%
0.89%
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
2013 2014 2015 2016 2017
Beginning of transfusion near-misses,
per year
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Beginning of transfusions, per hour and nurse shift2014-2017
0.00%
0.50%
1.00%
1.50%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Beginning of transfusions, per hour and nurse shift, percent
0
2000
4000
6000
8000
10000
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Beginning of transfusions, per hour and nurse shift, number
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Acute transfusion reactions2010- 2017
28
0
10
20
30
40
50
60
70
80
YEAR 2010 YEAR 2011 YEAR 2012 YEAR 2013 YEAR 2014 YEAR 2015 YEAR 2016 YEAR 2017
AHTR-ABO (ERRORS) ATR-NON ABO FEBRILE DIGESTIVE ALLERGIC PULMONARY BACT SEPSIS
Pasive Hemovigilance Active &
Quarantine H
Retrospective
Active HV
Transfusional
Safety System
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Conclusions
• Electronic Transfusion safety systems are able to reduce errors
• Also, knowing real near-misses events rates
• Knowing who, when and where these rates are high
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Future stategies to improve transfusional safety
• Directed training and re- training follow-up
• Prohibiting transfusion to no well trained staff
• Reschudeling not urgent transfusion out of dangerous shifts
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Thanks….
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