Near-misses in sample collection and in bloodcomponent 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 recipentABO 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

1508114610

12914 1316013690

1443613461

4138 4543 4141 4466 46933348 3556

3494

36472516

13461906

2718 2962 27982259

3211

2943 2798 2929

0

2000

4000

6000

8000

10000

12000

14000

16000

year2008

year2009

year2010

year2011

year2012

year2013

year2014

year2015

year2016

year2017

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 4811,

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

Units transfused4358

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 thesample collection and in the blood componentstransfusion 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 checkingsperformed

Missmatches(Near-misses)

Near-missespercent

Blood samplecollections

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 ward2014-2017

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 shift2014-2017

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 shift2014-2017

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 reactions2010- 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….