Sample collection and sample handling errors submitted to the transfusion error surveillance system, 2006 to 2015

Area of Science:

• Transfusion Medicine
• Patient Safety
• Clinical Pathology

Background:

• Canadian transfusion-related errors are voluntarily reported to enhance transfusion safety.
• This analysis focuses on sample collection (SC) and sample handling (SH) errors from a national tracking system.

Purpose of the Study:

• To analyze trends in sample collection and sample handling errors in Canadian blood transfusions from 2006 to 2015.
• To investigate the impact of institutional policies and error detection mechanisms on transfusion error rates.

Main Methods:

• Extracted error data from 23 participating Canadian sites between 2006 and 2015.
• Calculated error rates, including "wrong blood in tube" (WBIT), based on samples received in the blood bank.
• Conducted a survey to gather information on institutional policies and error detection practices.

Main Results:

• Over 42,000 SC and 14,000 SH errors were reported.
• Low-severity and high-severity SC/SH errors increased from 2006 to 2015.
• The WBIT rate significantly decreased from 12 to 5.8 per 10,000 samples (p < 0.0001).
• Sites with error detection mechanisms, like second sample requirements, showed lower error rates.

Conclusions:

• While WBIT errors have declined, low-severity errors are increasing, possibly due to better reporting.
• There is significant site-to-site variability in WBIT rates.
• Further prevention studies are crucial to inform updated blood transfusion standards and eliminate errors.