BACKGROUND: Haemovigilance is defined as the surveillance of adverse reactions occurring in donors and in recipients of blood components and as epidemiological surveillance of donors. The ultimate purpose of haemovigilance is to prevent the repetition of adverse events and reactions. Since the 2002/98/EC Directive came into force, the introduction of haemovigilance systems has become a priority for all countries in the European Community. The Italian haemovigilance system is essentially in line with the Directive, although it does not include surveillance of adverse events in donors and does not have a national level of registration of severe incidents connected with the collection, processing and storage of blood and blood components. Epidemiological surveillance of donors has been performed nationally since 1989 for HIV and since 1999 for HBV, HCV and Treponema pallidum. Surveillance of adverse events in recipients was started at the end of 2004. MATERIALS AND METHODS: The national form proposed for notifying adverse reactions (PETRA) was prepared by the National Institute of Health and distributed to all Transfusion Structures. RESULTS: The data collected (adverse reactions, errors, and near miss errors) came from 21.0% of the Transfusion Structures in 2004 and 38.4% in 2005. The system monitored 49.6 % of all the units distributed in Italy. Overall 1,495 adverse reactions were reported, which is equivalent to 0.8 reactions/1,000 units of blood components distributed. There were 16 reports of errors involving transfusions to the wrong patient. Not all the Transfusion Structures sent their data using the PETRA form. From the 986 PETRA forms received, it was possible to analyse the relevance of the transfusion, the outcome of the patient, the type of blood component involved, the type of error and the type of near miss error. CONCLUSIONS: This study is the first Italian report on transfusion errors and adverse reactions.
BACKGROUND: Haemovigilance is defined as the surveillance of adverse reactions occurring in donors and in recipients of blood components and as epidemiological surveillance of donors. The ultimate purpose of haemovigilance is to prevent the repetition of adverse events and reactions. Since the 2002/98/EC Directive came into force, the introduction of haemovigilance systems has become a priority for all countries in the European Community. The Italian haemovigilance system is essentially in line with the Directive, although it does not include surveillance of adverse events in donors and does not have a national level of registration of severe incidents connected with the collection, processing and storage of blood and blood components. Epidemiological surveillance of donors has been performed nationally since 1989 for HIV and since 1999 for HBV, HCV and Treponema pallidum. Surveillance of adverse events in recipients was started at the end of 2004. MATERIALS AND METHODS: The national form proposed for notifying adverse reactions (PETRA) was prepared by the National Institute of Health and distributed to all Transfusion Structures. RESULTS: The data collected (adverse reactions, errors, and near miss errors) came from 21.0% of the Transfusion Structures in 2004 and 38.4% in 2005. The system monitored 49.6 % of all the units distributed in Italy. Overall 1,495 adverse reactions were reported, which is equivalent to 0.8 reactions/1,000 units of blood components distributed. There were 16 reports of errors involving transfusions to the wrong patient. Not all the Transfusion Structures sent their data using the PETRA form. From the 986 PETRA forms received, it was possible to analyse the relevance of the transfusion, the outcome of the patient, the type of blood component involved, the type of error and the type of near miss error. CONCLUSIONS: This study is the first Italian report on transfusion errors and adverse reactions.
Entities:
Keywords:
PETRA; adverse reactions; errors; haemovigilance; near miss errors; transfusion
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