Error management of emergency transfusions: A surveillance system to detect safety risks in day to day practice

Schmidt-Hieber, Martin; Schuster, Ronny; Nogai, Axel; Thiel, Eckhard; Hopfenmüller, Werner; Notter, Michael

doi:10.1016/j.transci.2006.06.001

« Previous Next »Transfusion and Apheresis Science
Volume 35, Issue 2 , Pages 125-130, October 2006

Error management of emergency transfusions: A surveillance system to detect safety risks in day to day practice

Martin Schmidt-Hieber
- Medizinische Klinik III (Hämatologie, Onkologie und Transfusionsmedizin), Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
- Corresponding author. Tel.: +49 30 8445 2310; fax: +49 30 8445 4468.
Ronny Schuster
- Medizinische Klinik III (Hämatologie, Onkologie und Transfusionsmedizin), Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
Axel Nogai
- Medizinische Klinik III (Hämatologie, Onkologie und Transfusionsmedizin), Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
Eckhard Thiel
- Medizinische Klinik III (Hämatologie, Onkologie und Transfusionsmedizin), Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
Werner Hopfenmüller
- Institute for Medical Statistics, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
Michael Notter
- Medizinische Klinik III (Hämatologie, Onkologie und Transfusionsmedizin), Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany

Received 14 February 2006; received in revised form 25 May 2006; accepted 1 June 2006.

Abstract

Acute hemolysis due to AB0-incompatibility caused by transfusion of red blood cell concentrates (RBCC) to the wrong recipient is one of the major causes of transfusion-related death. As part of our policy to improve quality and safety in emergency transfusion, we have developed a standardized surveillance system for supplying RBCC in emergency situations. This surveillance system involves the implementation of a standardized set of basic data transmitted from the requesting unit to the blood bank by phone and a scoring system to check for compliance with guidelines and errors in daily routines. Communication deficiencies and delayed pretransfusion sampling were the most common errors.

Keywords: Emergency transfusion, Error management, Surveillance, Mistransfusion