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Autologous donation error rates in Canada
M Goldman1, S Rémy-Prince, A Trépanier
1Canadian Red Cross Society, Blood Services, Transfusion Center of Quebec, Canada.
Insights
Autologous blood donations, while reducing some risks, still experience frequent clerical errors. These errors, including labeling and delivery mistakes, highlight that autologous transfusions are not risk-free.
Area of Science:
- Transfusion Medicine
- Patient Safety
- Blood Banking
Background:
- Autologous blood transfusions eliminate certain risks associated with allogeneic donations.
- However, clerical errors can still occur in autologous donation processes.
- Differences in donor selection and patient expectations may alter the impact of errors in autologous versus allogeneic donations.
Purpose of the Study:
- To estimate the error rates in Canadian autologous blood donation programs.
- To identify the types and frequencies of errors occurring in these programs.
Main Methods:
- A comprehensive review of autologous donation error data in Canada from 1989 to 1995.
- Data collection involved questionnaires sent to hospitals and Canadian Red Cross centers, and a review of quality assurance reports.
- Error rates were calculated based on the number of units collected.
Main Results:
- The Montreal autologous donation program reported 113 errors for 16,873 units (1/149 units).
- Frequent errors included late receipt of units (25%) and delivery to the wrong hospital (23%).
- Other Canadian programs reported 166 errors for approximately 53,500 units (1/322 units), with labeling (48%) and component preparation (25%) being most common. One unit was transfused to the wrong recipient.
Conclusions:
- Clerical errors are a significant concern in autologous blood donation programs.
- Autologous transfusions carry inherent risks that necessitate careful management and error reduction strategies.
Background:
Although certain transfusion risks are eliminated by the use of autologous blood, clerical errors may still occur. In addition, because of differences in donor selection criteria and donor-patient expectations, the consequences of certain errors may be different in autologous and allogeneic donations.
Study Design And Methods:
In January 1996, autologous donation error rates in Canada from 1989 to November 1995 were estimated by 1) a detailed questionnaire sent to hospitals supplied by the Canadian Red Cross, Blood Services, Transfusion Center of Quebec at Montreal autologous donation program (n = 31), 2) a review of that institution's quality assurance non-compliance reports, and 3) a detailed questionnaire sent to other Canadian Red Cross centers with autologous donation programs (n = 16) and hospital-based autologous programs in Canada (n = 3). The total number of autologous donations collected was determined from Canadian Red Cross annual reports and information supplied by hospital-based programs.
Results:
There were 113 errors reported for 16,873 units collected by the Montreal center (1/149 units) based on collection center and hospital data. The most frequent errors were the late receipt of units for surgery (25% of errors) or the receipt of units in the wrong hospital (23%). Other Canadian programs reported 166 errors for approximately 53,500 units collected (1/322 units). However, this figure was based mainly on collection center, and not hospital, data. The most frequent errors were in labeling (48%) and component preparation (25%). One unit of autologous fresh-frozen plasma was transfused to the wrong recipient. Errors were more frequent if components were produced, if units were drawn in hospitals for interhospital transfer, or it units were shipped between Red Cross centers.
Conclusion:
Errors are not infrequent in autologous donation programs. Autologous transfusion should not be considered as being without risk.