ABSTRACT
BACKGROUND: The MERS-TM assists hospital transfusion services to identify, analyze, and correct system events relating to the delivery of blood to patients. METHODS: The MERS-TM system was used from February of 1999 to December 2002. All reported near-miss and actual events were recorded and analyzed. RESULTS: During these 47 months, 4670 events were reported by the transfusion service. Of these events, 94% were classified as a near-miss event and 93% were detected before the blood product was administered. No ABO-incompatible transfusions were detected despite transfusion of 50,137 units of red blood cells. High severity events with the potential for patient harm accounted for 241 (5%) of the 4670 events. Nursing related events accounted for 188 (78%) of the high severity events. In one out of 4430 (0.023%) samples tested, a high severity sample-testing event was detected. In one out of 1550 (0.06%) samples collected, a high severity sample-collection event was detected. CONCLUSION: An event reporting system is essential if one is to determine where and how often events are occurring within the transfusion process.
Subject(s)
Blood Transfusion/standards , Database Management Systems , Medical Errors/classification , Medical Staff, Hospital/standards , Risk Management/methods , Data Collection , Database Management Systems/statistics & numerical data , Humans , Medical Errors/prevention & control , Medical Errors/statistics & numerical data , Medical Staff, Hospital/education , Ontario , Risk Management/statistics & numerical data , Safety , Transfusion ReactionSubject(s)
Hepatitis C/transmission , Transfusion Reaction , Blood Donors , Humans , Retrospective StudiesABSTRACT
BACKGROUND: Current blood transfusion standards in Canada and the United States permit transfusion of ABO-nonidentical platelets when ABO-identical platelets are not available. This practice increases the availability of platelets, a component in chronic shortage in Ontario, Canada because of the 5-day shelf-life. The impact of transfusing ABO-nonidentical platelets on patient outcomes is unknown. STUDY DESIGN AND METHODS. A retrospective review of 1721 patients who had cardiovascular surgery between November 1989 and December 1999 and who had also received a platelet transfusion perioperatively was conducted. The impact of platelet and plasma incompatibility on clinical outcomes was analyzed. RESULTS: The analysis included 1691 patients who were divided into two groups according to the compatibility of the first platelet transfusion received: ABO-identical platelet transfusion (n = 1008) and ABO-nonidentical platelet transfusion (n = 683). The only difference in baseline characteristics between the two groups was that there were more urgent cases in the ABO-identical platelet transfusion group (p = 0.04). There were no significant differences in mortality at 30 days (10% for both groups, p = NS) or in postoperative length of stay (median, 7.0 days for both groups, p = NS). No significant differences were found with respect to the use of blood components, indices of bleeding, incidence of infection, or platelet CCIs. CONCLUSION: Transfusion of ABO-nonidentical platelets in patients undergoing cardiovascular surgery is not associated with an adverse impact on patient outcome.
