Masaki Ri1, Masanobu Kasai2, Akio Kohno3, Masaru Kondo4, Masashi Sawa5, Tomohiro Kinoshita6, Isamu Sugiura7, Yasuo Miura8, Kazuhito Yamamoto9, Toshiki I Saito10, Yukiyasu Ozawa11, Tadashi Matsushita12, Hidefumi Kato13. 1. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Blood Transfusion and Cell Therapy, Nagoya City University Hospital, Nagoya, Japan. Electronic address: rrmasaki@ybb.ne.jp. 2. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Hematology and Oncology, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan. 3. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Hematology and Oncology, Konan Kosei Hospital, Konan, Japan. 4. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Okazaki City Hospital, Okazaki, Japan. 5. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan. 6. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Japanese Red Cross Aichi Blood Center, Seto, Japan. 7. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Blood Transfusion and Cell Therapy Center, Toyohashi Municipal Hospital, Toyohashi, Japan. 8. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Transfusion Medicine and Cell Therapy, Fujita Health University Hospital, Toyoake, Japan. 9. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Hematology and Cell Therapy, Aichi Cancer Center Hospital, Nagoya, Japan. 10. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan. 11. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Hematology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan. 12. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan. 13. Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan; Department of Transfusion Medicine, Aichi Medical University Hospital, Nagakute, Japan.
Abstract
BACKGROUND: Despite recent progress in blood systems, transfusion errors can occur at any time from the moment of collection through to the transfusion of blood and blood products. This study investigated the actual statuses of blood transfusion errors at institutions of all sizes in Aichi prefecture. MATERIALS AND METHODS: We investigated 104 institutions that perform 98 % of the blood transfusions in Aichi prefecture, and investigated the errors (incidents/accidents) that occurred at these facilities over 6 months (April to September, 2017). Incident/accident data were collected from responses to questionnaires sent to each institution; these were classified according to the categories and risk levels. RESULTS: Ninety-seven of the 104 institutions (93.3 %) responded to the questionnaire; a total of 688 incidents/accidents were reported. Most (682 cases; 99.2 %), were classified as risk level 2; however, 6 were level 3 and over, which included problems with autologous transfusion and inventory control. Approximately one-half of the incidents/accidents (394 cases; 57.3 %), were related to verification and the actual administration of blood products at the bedside; more than half of these incidents/accidents occurred at large-volume institutions. Meanwhile, a high frequency of incidents/accidents related to transfusion examination and labeling of blood products was observed at small- or medium-sized institutions. The reasons for most of these errors were simple mistakes and carelessness by the medical staff. CONCLUSIONS: Our results emphasize the importance of education, operational training, and compliance instruction for all members of the medical staff despite advances in electronic devices meant to streamline transfusion procedures.
BACKGROUND: Despite recent progress in blood systems, transfusion errors can occur at any time from the moment of collection through to the transfusion of blood and blood products. This study investigated the actual statuses of blood transfusion errors at institutions of all sizes in Aichi prefecture. MATERIALS AND METHODS: We investigated 104 institutions that perform 98 % of the blood transfusions in Aichi prefecture, and investigated the errors (incidents/accidents) that occurred at these facilities over 6 months (April to September, 2017). Incident/accident data were collected from responses to questionnaires sent to each institution; these were classified according to the categories and risk levels. RESULTS: Ninety-seven of the 104 institutions (93.3 %) responded to the questionnaire; a total of 688 incidents/accidents were reported. Most (682 cases; 99.2 %), were classified as risk level 2; however, 6 were level 3 and over, which included problems with autologous transfusion and inventory control. Approximately one-half of the incidents/accidents (394 cases; 57.3 %), were related to verification and the actual administration of blood products at the bedside; more than half of these incidents/accidents occurred at large-volume institutions. Meanwhile, a high frequency of incidents/accidents related to transfusion examination and labeling of blood products was observed at small- or medium-sized institutions. The reasons for most of these errors were simple mistakes and carelessness by the medical staff. CONCLUSIONS: Our results emphasize the importance of education, operational training, and compliance instruction for all members of the medical staff despite advances in electronic devices meant to streamline transfusion procedures.