Near-misses in sample collection and in blood component ... · PDF file Near-misses in sample...

Click here to load reader

  • date post

    12-Jun-2020
  • Category

    Documents

  • view

    0
  • download

    0

Embed Size (px)

Transcript of Near-misses in sample collection and in blood component ... · PDF file Near-misses in sample...

  • Near-misses in sample collection and in blood component transfusion. An incidence study

    using an electronic transfusion safety system

    1

    Dr. José-Luis Bueno Hematology and Hemotherapy Department

    Hospital Universitario Puerta de Hierro Majadahonda (Madrid)

  • Conflict of Interest Disclosure

    • Grifols – Consultancy

    – Honoraria

    • Janssen – Consultancy

    – Honoraria

    • PRoPosit – CEO

    – Medical Director

    • Sanofi – Consultancy – Honoraria – Medical writting – Advisory Committees

    • Onega+ – Consultancy

    I hereby declare the following potential conflicts of interest concerning

    my presentation:

  • 4

  • Errors ocurring during transfusion

    of a blood component

    ABO incompatible

    transfusion

    Death as result of an incorrect

    blood component transfusion

    5

    • SHOT 1996-2003

    • Risk of an error ocurring during transfusion of a blood component 1:16.500

    • Risk of an ABO incompatible transfusion 1:100.000

    • Risk of a death as result of an incorrect blood component transfusion 1:1.500.000

  • Transfusion with unknown donor and recipent ABO typing, in caucasian matchs in around 63%

    A NEG, 6.83%

    A POS, 36.80%

    AB NEG, 0.55%

    AB POS, 3.20%

    B NEG, 1.29% B POS, 8.25%

    O NEG, 6.26%

    O POS, 36.82%

  • 1 ABO Hemolitic Transfusion reaction

    Near-misses

    2 asintomatic ABO errors

  • 10136

    12172

    13897

    15081 14610

    12914 13160 13690

    14436 13461

    4138 4543 4141 4466 4693

    3348 3556

    3494

    3647 2516

    1346 1906

    2718 2962 2798 2259 3211

    2943 2798 2929

    0

    2000

    4000

    6000

    8000

    10000

    12000

    14000

    16000

    year 2008

    year 2009

    year 2010

    year 2011

    year 2012

    year 2013

    year 2014

    year 2015

    year 2016

    year 2017

    Puerta de Hierro-Majadahonda Hospital. Transfusions 2008-2017

    RBCs

    Plasma units

    Platelet units

    -7,3

    20.881 18.906

  • Blood sample verification. Before 2013

    Second blood sample

    collection in new patient

    ABO Rh checking against

    previous record

  • Blood sample verification. Before 2013

    Second blood sample collection in new patient

  • Bed-side verification. Before 2013

    “Wet test” blood group checking in the bedside

  • Bed-side verification. Before 2013

    “Wet test” blood group checking in the bedside

  • 13

    135 events/ 123941 transfusions

    10,9 events/ 10.000 transfusions

  • Hemovigilance between 2010 y 2012 HUPHM

    RBC % PLT % FFP % Total

    HTR (ABO) 4 0,9 0 0,0 0 0,0 4 0,6

    Febrile or hypotensive non hemolytic 37 8,5 4 4,7 1 0,8 42 6,4

    Allergic 5 1,1 3 3,5 25 18,8 33 5,0

    TRALI/TACO 0 0,0 0 0,0 0 0,0 0 0,0

    Bacterial Contamination 1 0,2 0 0,0 0 0,0 1 0,2

    Near miss 1 0,2 0 0,0 0 0,0 2 0,3

    Total 48 11,

    0 7 8,3 26 19,5 81 12,4

    Units transfused 4358

    8 8478 13300 65366

    By 10.000 11,0 8,3 19,5 12,4

    Haemovigilance Report 2010-2012

    14

    1 ABO error per 11.000 units transfused

  • ERRORS

    Near-misses

  • Blood sample verification

    16

    Blood-Bank verification

    Bed-side patient and blood

    component checking

  • USERDATE TIME WARD BLOOD COMPT. CORRECT?PATIENT

    Gricode web based software

  • Objective

    Define the incidence of near-misses in the sample collection and in the blood components transfusion using our electronic safety system

  • Methods

    • Observational, retrospective, one-center study

    • Near-misses incidence in sample collection and blood components transfusion

    • Years 2014-2017

    • Analysis by year, time, nurse shift, ward, operator

  • Near-misses in SC & BCT 2014-2017

    Number of checkings performed

    Missmatches (Near-misses)

    Near-misses percent

    Blood sample collections

    55.636 1.995 3,59%

    Beginning of transfusions

    81.168* 548 0,67%

  • Blood sample collection

    21

  • 3.05%

    2.21% 2.58% 2.53%

    6.88%

    8.09%

    0.00%

    1.00%

    2.00%

    3.00%

    4.00%

    5.00%

    6.00%

    7.00%

    8.00%

    9.00%

    2013 2014 2015 2016 2017 2018

    Blood sample collection near-misses,

    per year

  • 0001- 713 22 3,09% 0002- 1041 72 6,92% 0003- 41 4 9,76% 0004- 1006 37 3,68% 0005- 1709 70 4,10% 0006- 5311 59 1,11% 0010- 11380 446 3,92%

    0011- 1109 66 5,95% 0012- 1279 60 4,69% 0013- 338 49 14,50% 0014- 388 18 4,64%

    HDD Qx 8340 61 0,73%

    Blood sample collection near-misses per ward 2014-2017

    Ward Checkings Miss-matches Miss-matches %

  • 0.0%

    2.0%

    4.0%

    6.0%

    8.0%

    10.0%

    0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

    Miss-matches percent per hour

    0

    2000

    4000

    6000

    8000

    0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

    Sample collections per hour, number

    Blood sample collection near-misses per hour and nurse shift 2014-2017

  • 25

    Beginning of transfusion

  • 2.74%

    0.70% 0.64%

    0.40%

    0.89%

    0.00%

    0.50%

    1.00%

    1.50%

    2.00%

    2.50%

    3.00%

    2013 2014 2015 2016 2017

    Beginning of transfusion near-misses,

    per year

  • Beginning of transfusions, per hour and nurse shift 2014-2017

    0.00%

    0.50%

    1.00%

    1.50%

    0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

    Beginning of transfusions, per hour and nurse shift, percent

    0

    2000

    4000

    6000

    8000

    10000

    0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

    Beginning of transfusions, per hour and nurse shift, number

  • Acute transfusion reactions 2010- 2017

    28

    0

    10

    20

    30

    40

    50

    60

    70

    80

    YEAR 2010 YEAR 2011 YEAR 2012 YEAR 2013 YEAR 2014 YEAR 2015 YEAR 2016 YEAR 2017

    AHTR-ABO (ERRORS) ATR-NON ABO FEBRILE DIGESTIVE ALLERGIC PULMONARY BACT SEPSIS

    Pasive Hemovigilance Active & Quarantine H

    Retrospective

    Active HV

    Transfusional

    Safety System

  • Conclusions

    • Electronic Transfusion safety systems are able to reduce errors

    • Also, knowing real near-misses events rates

    • Knowing who, when and where these rates are high

  • Future stategies to improve transfusional safety

    • Directed training and re- training follow-up

    • Prohibiting transfusion to no well trained staff

    • Reschudeling not urgent transfusion out of dangerous shifts

  • Thanks….