Systematic Workup of Transfusion Reactions Reveals Passive Co-Reporting of Handling Errors

Abstract

Introduction

Reporting of transfusion reactions is good practice and required by many guidelines. Errors in the transfusion chain can also lead to severe patient reactions and depend on active error reporting. We aimed to characterize transfusion incidents and asked whether workup of transfusion reactions may also contribute to revealing logistical errors.

Methods

Transfusion medical records from 2011 to 2019 at our tertiary medical centre, as well as forensic autopsy reports, digitized sections, and court records from 1990 to 2019 were analysed. A total of 230,845 components were transfused between 2011 and 2019 at our own institution.

Results

Overall, 322 transfusion incidents were reported. Of these, 279 were from our own institution, corresponding to a frequency of 0.12% of all transfusions. The distribution of reaction types is consistent with the literature, with allergic reactions (55.9%), febrile-non-hemolytic reactions (FNHTR, 24.2%), hemolytic reactions (3.4%) and other types at smaller frequencies (<3%). Twenty-nine (10.4%) of the 279 reports revealed logistical errors, including hemoglobin above guideline threshold (4.3%), incorrect or non-performed bedside tests (3.2%), inadequate patient identification (2.5%), laboratory and issuing errors, missed product checks or failure to follow recommendations (1.1% each). Eight of 29 (27.5%) of the logistical errors were detected by serendipity during workup of incident reports. In addition, 8/932 autopsy cases under code A14 (medical treatment errors) were found to be transfusion-associated (0.9%).

Conclusion

Systematic workup of transfusion incidents can identify previously undetected errors in the transfusion chain. Passive reporting of errors through the recording of side effects may serve as a tool to assess more closely assess the frequency and quality of handling errors in real life, and thus serve to improve patient safety.

Keywords:

• adverse transfusion reactions
• near miss
• hemovigilance
• allergic transfusion reaction

Data Sharing Statement

The data that support the findings of this study are not publicly available because they contain information that could compromise the privacy of research participants but are available from the corresponding author (R.H.).

Statement of Ethics

The research was reviewed for compliance with the guidelines for human studies in accordance with the Declaration of Helsinki of the World Medical Association. A positive ethical vote was obtained from the Ethics Committee of the Medical Faculty of the University of Leipzig (reference: 499/20-ek). Written informed consent was not required, but anonymity was granted.

Author Contributions

E.N. developed the concept of the study, carried out the data collection, analysed the results, wrote the manuscript and created the figures and tables. She agreed on the journal to which the article was submitted. R.H. developed the concept of the study, helped with the acquisition and interpretation of the data, corrected and reviewed the manuscript critically. He agreed on the journal to which the article was submitted. J.D. initiated the study, developed the study design, helped with the acquisition of data and critically reviewed the manuscript. He agreed on the journal to which the article was submitted. All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors have no conflicts of interest to declare for this work.

Additional information

Funding

Supported by the Open Access Publishing Fund of Leipzig University.