Root cause analysis of non-infectious transfusion complications and the lessons learnt

Farheen Karim, Bushra Moiz, Naseem Shamsuddin, Safia Naz, Mohammad Khurshid

Research output: Contribution to journalArticlepeer-review

17 Citations (Scopus)

Abstract

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.

Original languageEnglish
Pages (from-to)111-117
Number of pages7
JournalTransfusion and Apheresis Science
Volume50
Issue number1
DOIs
Publication statusPublished - Feb 2014

Keywords

  • Adverse effects
  • Blood transfusion
  • Non-infectious complications
  • Root cause analysis

Fingerprint

Dive into the research topics of 'Root cause analysis of non-infectious transfusion complications and the lessons learnt'. Together they form a unique fingerprint.

Cite this