TY - JOUR
T1 - Root cause analysis of non-infectious transfusion complications and the lessons learnt
AU - Karim, Farheen
AU - Moiz, Bushra
AU - Shamsuddin, Naseem
AU - Naz, Safia
AU - Khurshid, Mohammad
PY - 2014/2
Y1 - 2014/2
N2 - Background: Transfusion of blood and blood products can be associated with hazards which may be at times fatal. Timely reporting of transfusion reactions is imperative for root cause analysis and their prevention in future. Methods: We retrospectively reviewed the transfusion reactions at our institution during last seven years. The data was retrieved from our computerized blood bank information system and by reviewing the medical charts of patients. The frequency of adverse effects, implicated products, wrong blood transfusion and its outcome were observed. Results and conclusions: During study period (2006-2012), a total of 393,662 blood or blood products were transfused. There were 458 adverse events with an estimated rate of 1.16 per 1000 blood products administered. During 2011-2012, 121 transfusion reactions were reported of 119,921 transfused units. The most common adverse effects were allergic reactions (70 episodes of 121 or 57.8%) followed by febrile non hemolytic transfusion reactions or FNHTR (43 events of 121 or 35.5%). Transfusion associated dyspnea, circulatory overload and transfusion associated lung injury were less frequent. During the study period, 142,066 red cell units were transfused with nine recognized ABO-mismatch transfusions and two fatalities. The computed incidence of ABO-mismatch transfusion was 1 in 15,785 with a mortality rate of 1 in 71,033 units transfused. Etiology included: errors in final bed side check (n= 5), blood bank clerical errors (n= 3) and mislabeled tube (n= 1). A review of these cases prompted hospital transfusion committee for re-enforcing policies and protocols to minimize accidental ABO incompatible transfusions. We concluded that urticaria and FNHTR are the most frequent transfusion reactions in our setting. ABO mismatched blood transfusions are rare but preventable errors and result mainly from clerical imprecisions.
AB - Background: Transfusion of blood and blood products can be associated with hazards which may be at times fatal. Timely reporting of transfusion reactions is imperative for root cause analysis and their prevention in future. Methods: We retrospectively reviewed the transfusion reactions at our institution during last seven years. The data was retrieved from our computerized blood bank information system and by reviewing the medical charts of patients. The frequency of adverse effects, implicated products, wrong blood transfusion and its outcome were observed. Results and conclusions: During study period (2006-2012), a total of 393,662 blood or blood products were transfused. There were 458 adverse events with an estimated rate of 1.16 per 1000 blood products administered. During 2011-2012, 121 transfusion reactions were reported of 119,921 transfused units. The most common adverse effects were allergic reactions (70 episodes of 121 or 57.8%) followed by febrile non hemolytic transfusion reactions or FNHTR (43 events of 121 or 35.5%). Transfusion associated dyspnea, circulatory overload and transfusion associated lung injury were less frequent. During the study period, 142,066 red cell units were transfused with nine recognized ABO-mismatch transfusions and two fatalities. The computed incidence of ABO-mismatch transfusion was 1 in 15,785 with a mortality rate of 1 in 71,033 units transfused. Etiology included: errors in final bed side check (n= 5), blood bank clerical errors (n= 3) and mislabeled tube (n= 1). A review of these cases prompted hospital transfusion committee for re-enforcing policies and protocols to minimize accidental ABO incompatible transfusions. We concluded that urticaria and FNHTR are the most frequent transfusion reactions in our setting. ABO mismatched blood transfusions are rare but preventable errors and result mainly from clerical imprecisions.
KW - Adverse effects
KW - Blood transfusion
KW - Non-infectious complications
KW - Root cause analysis
UR - http://www.scopus.com/inward/record.url?scp=84897023306&partnerID=8YFLogxK
U2 - 10.1016/j.transci.2013.10.004
DO - 10.1016/j.transci.2013.10.004
M3 - Article
C2 - 24239270
AN - SCOPUS:84897023306
SN - 1473-0502
VL - 50
SP - 111
EP - 117
JO - Transfusion and Apheresis Science
JF - Transfusion and Apheresis Science
IS - 1
ER -