A survey of blood transfusion errors in Aichi Prefecture in Japan: Identifying major lapses threatening the safety of transfusion recipients.

Blood Transfusion / methods Humans Japan Medical Errors / statistics & numerical data Retrospective Studies Surveys and Questionnaires Transfusion Reaction / complications
Aichi Prefecture Human error Japan Malpractice Questionnaires Transfusion survey

Journal

Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis
ISSN: 1473-0502
Titre abrégé: Transfus Apher Sci
Pays: England
ID NLM: 101095653

Informations de publication

Date de publication:
Jun 2020
Historique:
received: 18 09 2019
revised: 18 12 2019
accepted: 06 01 2020
pubmed: 6 2 2020
medline: 15 1 2021
entrez: 6 2 2020
Statut: ppublish

Résumé

Despite recent progress in blood systems, transfusion errors can occur at any time from the moment of collection through to the transfusion of blood and blood products. This study investigated the actual statuses of blood transfusion errors at institutions of all sizes in Aichi prefecture. We investigated 104 institutions that perform 98 % of the blood transfusions in Aichi prefecture, and investigated the errors (incidents/accidents) that occurred at these facilities over 6 months (April to September, 2017). Incident/accident data were collected from responses to questionnaires sent to each institution; these were classified according to the categories and risk levels. Ninety-seven of the 104 institutions (93.3 %) responded to the questionnaire; a total of 688 incidents/accidents were reported. Most (682 cases; 99.2 %), were classified as risk level 2; however, 6 were level 3 and over, which included problems with autologous transfusion and inventory control. Approximately one-half of the incidents/accidents (394 cases; 57.3 %), were related to verification and the actual administration of blood products at the bedside; more than half of these incidents/accidents occurred at large-volume institutions. Meanwhile, a high frequency of incidents/accidents related to transfusion examination and labeling of blood products was observed at small- or medium-sized institutions. The reasons for most of these errors were simple mistakes and carelessness by the medical staff. Our results emphasize the importance of education, operational training, and compliance instruction for all members of the medical staff despite advances in electronic devices meant to streamline transfusion procedures.

Sections du résumé

BACKGROUND BACKGROUND
Despite recent progress in blood systems, transfusion errors can occur at any time from the moment of collection through to the transfusion of blood and blood products. This study investigated the actual statuses of blood transfusion errors at institutions of all sizes in Aichi prefecture.
MATERIALS AND METHODS METHODS
We investigated 104 institutions that perform 98 % of the blood transfusions in Aichi prefecture, and investigated the errors (incidents/accidents) that occurred at these facilities over 6 months (April to September, 2017). Incident/accident data were collected from responses to questionnaires sent to each institution; these were classified according to the categories and risk levels.
RESULTS RESULTS
Ninety-seven of the 104 institutions (93.3 %) responded to the questionnaire; a total of 688 incidents/accidents were reported. Most (682 cases; 99.2 %), were classified as risk level 2; however, 6 were level 3 and over, which included problems with autologous transfusion and inventory control. Approximately one-half of the incidents/accidents (394 cases; 57.3 %), were related to verification and the actual administration of blood products at the bedside; more than half of these incidents/accidents occurred at large-volume institutions. Meanwhile, a high frequency of incidents/accidents related to transfusion examination and labeling of blood products was observed at small- or medium-sized institutions. The reasons for most of these errors were simple mistakes and carelessness by the medical staff.
CONCLUSIONS CONCLUSIONS
Our results emphasize the importance of education, operational training, and compliance instruction for all members of the medical staff despite advances in electronic devices meant to streamline transfusion procedures.

Identifiants

DOI: 10.1016/j.transci.2020.102735 PMID: 32019735
pubmed: 32019735
pii: S1473-0502(20)30018-5
doi: 10.1016/j.transci.2020.102735
pii:
doi:

Types de publication

Journal Article

Langues

eng

Pagination

102735

Informations de copyright

Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Déclaration de conflit d'intérêts

Declaration of Competing Interest None of the Authors has a conflict of interest with any of the subject matter of this work.

Auteurs

Masaki Ri (M)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Blood Transfusion and Cell Therapy, Nagoya City University Hospital, Nagoya, Japan. Electronic address: rrmasaki@ybb.ne.jp.

Masanobu Kasai (M)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Hematology and Oncology, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan.

Akio Kohno (A)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Hematology and Oncology, Konan Kosei Hospital, Konan, Japan.

Masaru Kondo (M)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Okazaki City Hospital, Okazaki, Japan.

Masashi Sawa (M)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan.

Tomohiro Kinoshita (T)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Japanese Red Cross Aichi Blood Center, Seto, Japan.

Isamu Sugiura (I)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Blood Transfusion and Cell Therapy Center, Toyohashi Municipal Hospital, Toyohashi, Japan.

Yasuo Miura (Y)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Transfusion Medicine and Cell Therapy, Fujita Health University Hospital, Toyoake, Japan.

Kazuhito Yamamoto (K)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Hematology and Cell Therapy, Aichi Cancer Center Hospital, Nagoya, Japan.

Toshiki I Saito (TI)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan.

Yukiyasu Ozawa (Y)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Hematology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan.

Tadashi Matsushita (T)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan.

Hidefumi Kato (H)

Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Transfusion Medicine, Aichi Medical University Hospital, Nagakute, Japan.

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Classifications MeSH

questionsmedicales.fr › Thérapeutique › Biothérapie › Transfusion sanguine › A survey of blood transfusion errors in Aichi...
questionsmedicales.fr › Eucaryotes › Animaux › Chordés › Vertébrés › Mammifères › Eutheria › Primates › Haplorhini › Catarrhini › Hominidae › Humains › A survey of blood transfusion errors in Aichi...
questionsmedicales.fr › Régions géographiques › Iles › Japon › A survey of blood transfusion errors in Aichi...
questionsmedicales.fr › Établissements, main d'oeuvre et services de soins de santé › Services de santé › Erreurs médicales › A survey of blood transfusion errors in Aichi...
questionsmedicales.fr › Environnement et santé publique › Santé publique › Méthodes épidémiologiques › Caractéristiques des études épidémiologiques › Études épidémiologiques › Études de cohortes › Études rétrospectives › A survey of blood transfusion errors in Aichi...
questionsmedicales.fr › Environnement et santé publique › Santé publique › Méthodes épidémiologiques › Collecte de données › Enquêtes et questionnaires › A survey of blood transfusion errors in Aichi...
questionsmedicales.fr › Maladies du système immunitaire › Réaction transfusionnelle › A survey of blood transfusion errors in Aichi...