Reducing adverse events in blood transfusion.

Area of Science:

• Healthcare safety
• Transfusion medicine
• Patient risk assessment

Background:

• Increasing expenditure on blood safety has not matched attention to hospital transfusion chain safety.
• The Serious Hazards of Transfusion (SHOT) scheme collects data on transfusion errors.
• Opportunities for error exist throughout the transfusion process, from prescription to administration.

Purpose of the Study:

• To estimate the risk of errors within the hospital transfusion chain.
• To identify critical points where errors occur.
• To inform strategies for improving transfusion safety.

Main Methods:

• Analysis of Serious Hazards of Transfusion (SHOT) scheme reports from 1996-2003.
• Estimation of transfusion error rates, including ABO incompatible transfusions and incorrect blood component transfused (IBCT).

Main Results:

• The risk of any transfusion error is estimated at 1:16,500.
• The risk of an ABO incompatible transfusion is 1:100,000.
• The risk of death from an incorrect blood component transfused (IBCT) is approximately 1:1,500,000.
• Component collection and administration errors are the most frequent.

Conclusions:

• Significant risks of error persist within the hospital transfusion chain.
• Targeted interventions are needed to reduce transfusion errors, particularly at the administration stage.
• National initiatives aim to reduce ABO incompatible transfusions by 50% over 3-5 years.