Blood transfusion events--lessons learned from a complex process
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Dubeck, Deborah, author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body. ECRI (Organization), issuing body. Institute for Safe Medication Practices, issuing body.
- Publication:
- [Harrisburg, Pennsylvania] : Pennsylvania Patient Safety Authority, September 2016
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Medical Errors -- prevention & control Medical Errors -- statistics & numerical data Transfusion Reaction Forecasting Medical Errors -- trends Medication Errors -- statistics & numerical data Patient safety Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- From January 1, 2010, through December 31, 2014, healthcare facilities reported 19,687 events involving a blood transfusion to the Pennsylvania Patient Safety Authority. Of these reports, 19,492 (99%) were categorized as Incidents that did not result in patient harm. A majority of the events (16,513) were reported under the category of transfusions. The American Red Cross reports that more than 30 million transfusions of blood components are performed each year in the United States. Transfusion is not without serious risk, ranging from mild reactions to life-threatening conditions. Transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), and hemolytic transfusion reactions (HTR) represent the most common morbidity and mortality events reported nationally. Although not all transfusion-related events are caused by errors, this complex process has many critical decision points at which errors can occur; preparing and administering a transfusion is a multistep and multidisciplinary process. Pennsylvania Patient Safety Reporting System (PA-PSRS) data show staff are identifying errors and making corrections prior to the event resulting in harm to the patient. Hemovigilance surveillance programs, emerging both internationally and in the Unites States, seek to learn from both Serious Events and Incidents, to continually improve the safety of blood transfusions. Advances in donor screening; improved testing of the blood supply; use of emerging technology, such as barcoding; and improvements in transfusion medicine practices have been found to increase the safety of blood transfusion.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (9 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101693076 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101693076