对输血反应的系统分析揭示了处理错误的被动联合报告
Elisabeth Nitsche1,2, Jan Dreßler2, Reinhard Henschler1
1Department of Forensic Medicine, Institute of Legal Medicine, University of Leipzig, Leipzig, Saxony, Germany.
Journal of blood medicine
|August 14, 2023
概括
报告输血反应有助于识别输血链中的后勤错误. 分析这些事件可以揭示以前未被发现的错误,改善患者安全和输血实践.
科学领域:
- 输血医学 输血医学
- 患者安全 患者安全
- 改善医疗保健质量 改善医疗保健质量
背景情况:
- 输血反应需要根据指导方针认真报告.
- 输血链中的错误可能导致患者的严重后果.
- 积极的错误报告对于识别和减轻风险至关重要.
研究的目的:
- 描述输血事件及其报告.
- 调查是否分析输血反应可以发现后勤错误.
- 评估事件报告对患者安全的贡献.
主要方法:
- 对输血医疗记录 (2011-2019) 的回顾性分析.
- 包括法医解剖报告,数字化部分和法庭记录 (1990-2019).
- 对230,845个输血组件的分析.
主要成果:
- 报告了322起输血事件;279起 (0.12%) 来自该机构.
- 常见的反应:过敏 (55.9%),发烧性非溶血性 (24.2%),溶血性 (3.4%).
- 29个事件 (10.4%) 显示出后勤错误,其中27.5%在反应处理过程中偶然发现.
结论:
- 对输血事件的系统处理可以识别输血链中的错误.
- 通过副作用记录进行被动错误报告,可以更好地评估处理错误.
- 这个过程提高了现实生活中的错误检测和患者安全.
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