A summary of the Transfusion Error Surveillance System: 2008 - 2011

Area of Science:

• Hematology
• Patient Safety
• Public Health Surveillance

Background:

• Canada's blood system is globally recognized for safety.
• Transfusion errors can occur at any stage of the blood product chain.
• The Transfusion Error Surveillance System (TESS) monitors these errors.

Purpose of the Study:

• To analyze transfusion-related errors reported to TESS between 2008 and 2011.
• To identify trends and patterns in transfusion errors.
• To inform targeted interventions for improving blood safety.

Main Methods:

• Data collected from 12-15 hospitals across four Canadian provinces (2008-2011).
• Quarterly electronic reporting of transfusion errors to the Public Health Agency of Canada.
• Categorization of errors by detection time (pre- or post-transfusion) and potential patient impact.
• Calculation of error rates and grouping by hospital transfusion capacity.

Main Results:

• 34,088 transfusion-related errors reported from 2008-2011.
• 98.6% of errors detected before transfusion; most common were collection and handling errors.
• 1.4% of errors detected post-transfusion; 66 high potential severity, 16 adverse reactions (e.g., circulatory overload).

Conclusions:

• Canadian blood transfusions in participating hospitals are safe and efficient.
• TESS data identifies common and severe errors for targeted corrective actions.
• Surveillance data is crucial for continuous improvement in transfusion safety.