Reporting of near-miss events for transfusion medicine: improving transfusion safety.

BACKGROUND: Half of the reported serious adverse events from transfusion are a consequence of medical error. A no-fault medical-event reporting system for transfusion medicine (MERS-TM) was developed to capture and analyze both near-miss and actual transfusion-related errors. STUDY DESIGN AND METHODS: A prospective audit of transfusion-related errors was performed to determine the ability of MERS-TM to identify the frequency and patterns of errors. RESULTS: Events and near-miss events (total, 819) were recorded for a period of 19 months (median, 51/month). No serious adverse patient outcome occurred, despite these events, with the transfusion of 17,465 units of RBCs. Sixty-one events (7.4%) were potentially life-threatening or could have led to permanent injury (severity Level 1). Of most concern were 3 samples collected from the wrong patient, 13 mislabeled samples, and 22 requests for blood for the wrong patient. Near-miss events were five times more frequent than actual transfusion errors, and 68 percent of errors were detected before blood was issued. Sixty-one percent of events originated from patient areas, 35 percent from the blood bank, and 4 percent from the blood supplier or other hospitals. Repeat collection was required for 1 of every 94 samples, and 1 in 346 requests for blood components was incorrect. Education of nurses and alterations to blood bank forms were not by themselves effective in reducing severe errors. An artifactual 50-percent reduction in the number of errors reported was noted during a 6-month period when two chief members of the event-reporting team were on temporary leave. CONCLUSION: The MERS-TM allowed the recognition and analysis of errors, determination of patterns of errors, and monitoring for changes in frequency after corrective action was implemented. Although no permanent injury resulted from the 819 events, innovative mechanisms must be designed to prevent these errors, instead of relying on faulty informal checks to capture errors after they occur.

An in vitro method for predicting the efficacy of WBC separation using different starch preparations and anticoagulant ratios.

BACKGROUND: Separation of blood components depends on a number of factors, including the viscosity of the plasma and the number and size of the various cellular elements. To enhance granulocyte collection, it is common practice to alter the plasma environment by the addition of sedimenting agents such as hydroxyethyl starch. Recently, because of its prolonged persistence in the circulation, the higher-molecular-weight form of hydroxyethyl starch, Hespan (HP), has been replaced by the lower-molecular-weight form, pentastarch (PS). However, the yield appears to be lower. A rapid in vitro approach was used to permit comparison of the efficiency of separation of WBCs by the use of PS and HP and different ratios of anticoagulants that also alter the sedimenting characteristics of blood. STUDY DESIGN AND METHOD: Blood from individual persons was collected into sodium citrate at ratios of 1:8, 1:12, and 1:16. Samples were evaluated either before or after the addition of PS or HP and after centrifugation. RESULTS: The addition of HP increased the sedimentation rate to at least four times that of plasma (10.9 vs. 47.9 mm); PS approximately doubled the rate. Viscosity was altered by the introduction of either starch. These changes (ranging from a rate of 4.2 in HP with a 1:16 anticoagulant to 3.6 in PS with a 1:8 ratio of anticoagulant) reflected the anticipated effects of anticoagulant dilution and carbohydrate addition. Granulocyte recovery was highest, with a 1:12 anticoagulant ratio in all tests with HP producing the greatest yield (HP, 101%; PS, 89%; control, 78%). CONCLUSION: HP is far more effective than its lower-molecular-weight substitute PS in the generation of granulocytes in the buffy coat of whole blood. This method provides a simple, rapid, in vitro approach to evaluating the separating efficiency of solutions.

Reduction of plasma volume after storage of platelets in CP2D.

BACKGROUND: There has been concern that further deterioration might occur if stored platelets are centrifuged to reduce their volume. Although such centrifugation appears to have minimal effect on platelets in CPDA-1 (osmolarity, 470 mOsm) there is no information on the situation with CP2D (580 mOsm). STUDY DESIGN AND METHODS: Platelet concentrates from CP2D packs were sampled at 1 and 5 days and after centrifugation was used to reduce the plasma volume to 10 mL. The aggregation, hypotonic shock response, morphology, pH, and lactate, glucose, pCO2 and pO2 levels were assessed, and values were compared to those seen with CPDA-1. In addition, blood was collected from the same donors into both CP2D and standard sodium citrate anticoagulant in an anticoagulant-to-blood ratio of 1:8 and the aggregation response of the fresh platelets was measured. RESULTS: Collection of blood into CP2D results in an immediate reduction of the platelet aggregation response when compared to that found after collection of blood into sodium citrate or CPDA-1. Aggregation is further decreased after storage; however, these changes and those for hypotonic shock, pH, lactate, glucose, and pCO2 are similar to those seen for CPDA-1. Additional centrifugation did not cause further change. CONCLUSION: Platelets stored in CP2D have reduced in vitro function after 5 days of storage, but subsequent centrifugation to reduce the plasma volume does not further alter these platelets.