An Audit on Near-Miss Events in Transfusion Medicine: The Experience of the Teaching Hospital in Northeastern Malaysia

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

The rate of near misses in transfusion is important as it indicates situations with the potential of adverse outcome. The aim of this study was to assess the frequency of mislabeled and miscollected samples received by our transfusion medicine unit. This study was conducted from January to December 2009 in Transfusion Medicine Unit, Hospital Universiti Sains Malaysia. The total number of near-miss events reported and analysed over the 1-year period was 178 (0.40%). All mislabeled and miscollected samples and its location cases were identified. Mislabeled and miscollected (WBIT) samples were 66.3% and 33.7%, respectively. The highest number of mislabeled and miscollected samples was from accident and emergency unit and medical ward, respectively. Continuous monitoring and analysis of near misses data should be mandatory in order to improve the safety of transfusion.

Related collections

Most cited references 10

Record: found
Abstract: found
Article: not found

Transfusion errors in New York State: an analysis of 10 years' experience.

Jeremiah Sheehan, A E Voytovich, David E. J. Linden … (2000)

While public focus is on the risk of infectious disease from the blood supply, transfusion errors also contribute significantly to adverse outcomes. This study characterizes such errors. The New York State Department of Health mandates the reporting of transfusion errors by the approximately 256 transfusion services licensed to operate in the state. Each incident from 1990 through 1998 that resulted in administration of blood to other than the intended patient or the issuance of blood of incorrect ABO or Rh group for transfusion was analyzed. Erroneous administration was observed for 1 of 19, 000 RBC units administered. Half of these events occurred outside the blood bank (administration to the wrong recipient, 38%; phlebotomy errors, 13%). Isolated blood bank errors, including testing of the wrong specimen, transcription errors, and issuance of the wrong unit, were responsible for 29 percent of events. Many events (15%) involved multiple errors; the most common was failure to detect at the bedside that an incorrect unit had been issued. Transfusion error continues to be a significant risk. Most errors result from human actions and thus may be preventable. The majority of events occur outside the blood bank, which suggests that hospitalwide efforts at prevention may be required.

0 comments Cited 36 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

An international study of the performance of sample collection from patients.

W Dzik, N Heddle, R KEKOMÄKI … (2003)

Collection of a blood sample from the correct patient is the first step in the process of safe transfusion. The aim of this international collaborative study was to assess the frequency of mislabelled and miscollected samples drawn for blood grouping. Hospitals in 10 countries provided data on sample error rates during a period of at least 3 months, including the last quarter of 2001. Mislabelled samples were defined as those not meeting local criteria for acceptance by the laboratory. Miscollected samples [wrong-blood-in-tube (WBIT)] were defined as samples in which the blood group result differed from the result on file from prior testing. WBIT rates were corrected for the proportion of repeat samples and for undetectable errors occurring as a result of chance collection of blood from the wrong patient with the same ABO group. Participants also completed a questionnaire on current policies regarding sample collection. A total of 71 hospitals completed surveys describing policies related to sample collection. Sixty-two hospitals provided usable data on the frequency of mislabelled and miscollected samples. Mislabelled and miscollected samples were common. Based on results from over 690,000 samples, the median hospital performance resulted in a rate for mislabelling of 1 in every 165 samples (6.1 per 1000; interquartile range 1.2-17 per 1000). The presence of national patient identification systems in Sweden and Finland was associated with rates of miscollected samples that were too low to estimate. Outside these nations, miscollected samples demonstrating WBIT occurred at a median rate of 1 in every 1986 samples (0.5 per 1000; interquartile range <0.3-0.9 per 1000). There was great variation worldwide in the reported frequency of mislabelled samples, probably resulting from variation in policies for sample acceptance. Miscollected samples occurred at a more constant rate. The rate of mislabelled samples and miscollected samples is 1000-10,000-fold more frequent than the risk of viral infection. Rates of mislabelled samples and WBIT can be tracked as key indicators of performance of an important step in the clinical transfusion process. WBIT episodes represent important 'near-miss' errors. By providing baseline performance data for the collection of patient blood samples, this study may be useful in formulating future national standards of performance for sample collection from patients.

0 comments Cited 18 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

New technology for transfusion safety.

Walter Dzik (2006)

Hemovigilance programs from around the world document that the greatest risk to recipients of blood transfusion is human error, resulting in transfusion of the incorrect blood component. Errors in transfusion care have strong parallels with errors in medication administration. Errors often result from 'lapse' or 'slip' mistakes in which details of patient identification are overlooked. Three areas of transfusion are focal points for improved care: the labelling of the patient's pre-transfusion sample, the decision to transfuse and the final bedside check designed to prevent mis-transfusion. Both barcodes and radio-frequency identification technology, each ideally suited to matching alpha-numeric identifiers, are being implemented in order to improve performance sample labelling and the bedside check. The decision to transfuse should ultimately be enhanced through the use of nanotechnology sensors, computerised order entry and decision support systems. Obstacles to the deployment of new technology include resistance to change, confusion regarding the best technology, and uncertainty regarding the return-on-investment. By focusing on overall transfusion safety, deploying validated systems appropriate for both medication and blood administration, thoughtful integration of technology into bedside practice and demonstration of improved performance, the application of new technologies will improve care for patients in need of transfusion therapy.

0 comments Cited 13 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Journal

Title: Journal of Transfusion

Abbreviated Title: Journal of Transfusion

Publisher: Hindawi Limited

ISSN (Electronic): 2090-3081

Publication date Created: 2011

Publication date (Print): 2011

Volume: 2011

Issue:

Pages: 1-4

Article

DOI: 10.4061/2011/963090

SO-VID: f8af8188-e9b8-4bda-9034-10ac7bd1216b

License:

http://creativecommons.org/licenses/by/3.0/

History

Data availability:

An Audit on Near-Miss Events in Transfusion Medicine: The Experience of the Teaching Hospital in Northeastern Malaysia

Read this article at

Abstract

Related collections

Teaching and learning evolution

Most cited references 10

Transfusion errors in New York State: an analysis of 10 years' experience.

An international study of the performance of sample collection from patients.

New technology for transfusion safety.

Author and article information

Journal

Article

History

Comments

Comment on this article

Similar content 45

Most referenced authors 68