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

      Affiliations

    • Medizinische Klinik III (Hämatologie, Onkologie und Transfusionsmedizin), Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
    • Corresponding Author InformationCorresponding author. Tel.: +49 30 8445 2310; fax: +49 30 8445 4468.
    • ,
  • Ronny Schuster

      Affiliations

    • Medizinische Klinik III (Hämatologie, Onkologie und Transfusionsmedizin), Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
    • ,
  • Axel Nogai

      Affiliations

    • Medizinische Klinik III (Hämatologie, Onkologie und Transfusionsmedizin), Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
    • ,
  • Eckhard Thiel

      Affiliations

    • Medizinische Klinik III (Hämatologie, Onkologie und Transfusionsmedizin), Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
    • ,
  • Werner Hopfenmüller

      Affiliations

    • Institute for Medical Statistics, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
    • ,
  • Michael Notter

      Affiliations

    • Medizinische Klinik III (Hämatologie, Onkologie und Transfusionsmedizin), Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany

Received 14 February 2006 ,Revised 25 May 2006 ,Accepted 1 June 2006.

References 

  1. Caspari G, Alpen U, Greinacher A. The risk of transfusion to the wrong patient in Germany. Transfusion. 2002;42:1238–1239
  2. Lau FY, Cheng G. To err is human nature. Can transfusion errors due to human factors ever be eliminated?. Clin Chim Acta. 2001;313:59–67
  3. Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York State: an analysis of 10 years’ experience. Transfusion. 2000;40:1207–1213
  4. Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion. 1990;30:583–590
  5. Holness L, Knippen MA, Simmons L, Lachenbruch PA. Fatalities caused by TRALI. Transfus Med Rev. 2004;18:184–188
  6. Silliman CC, Ambruso DR, Boshkov LK. Transfusion-related acute lung injury. Blood. 2005;105:2266–2273
  7. Chiaroni J, Legrand D, Dettori I, Ferrera V. Analysis of ABO discrepancies occurring in 35 French hospitals. Transfusion. 2004;44:860–864
  8. Ibojie J, Urbaniak SJ. Comparing near misses with actual mistransfusion events: a more accurate reflection of transfusion errors. Br J Haematol. 2000;108:458–460
  9. Seed CR, Kiely P, Keller AJ. Residual risk of transfusion transmitted human immunodeficiency virus, hepatitis B virus, hepatitis C virus and human T lymphotrophic virus. Int Med J. 2005;35:592–598
  10. Gonzalez M, Regine V, Piccinini V, Vulcano F, Giampaolo A, Hassan HJ. Residual risk of transfusion-transmitted human immunodeficiency virus, hepatitis C virus, and hepatitis B virus infections in Italy. Transfusion. 2005;45:1670–1675
  11. Callum JL, Merkley LL, Coovadia AS, Lima AP, Kaplan HS. Experience with the medical event reporting system for transfusion medicine (MERS-TM) at three hospitals. Transfus Apher Sci. 2004;31:133–143
  12. Kaplan HS. Event reporting systems: MERS-TM, surveillance-seeing and using the data below the waterline. Dev Biol (Basel). 2005;120:173–177
  13. Murphy MF, Howell C. National Blood Transfusion Committee in England. Survey of the implementation of the recommendations in the Health Service Circular 2002/009 ‘Better Blood Transfusion’. Transfus Med. 2005;15:453–460
  14. Rebibo D, Hauser L, Slimani A, Herve P, Andreu G. The French Haemovigilance System: organization and results for 2003. Transfus Apher Sci. 2004;31:145–153
  15. Lau FY, Wong R, Chui CH, Ng E, Cheng G. Improvement in transfusion safety using a specially designed transfusion wristband. Transfus Med. 2000;10:121–124
  16. Davies A, Staves J, Kay J, Casbard A, Murphy MF. End-to-end electronic control of the hospital transfusion process to increase the safety of blood transfusion: strengths and weaknesses. Transfusion. 2006;46:352–364
  17. Baele PL, De Bruyere M, Deneys V, Dupont E, Flament J, Lambermont M, et al. Bedside transfusion errors. A prospective survey by the Belgium SAnGUIS Group. Vox Sang. 1994;66:117–121
  18. Dettenkofer M, Wenzler-Rottele S, Babikir R, Bertz H, Ebner W, Meyer E, et al. Hospital Infection Surveillance System for Patients with Hematologic/Oncologic Malignancies Study Group. Surveillance of nosocomial sepsis and pneumonia in patients with a bone marrow or peripheral blood stem cell transplant: a multicenter project. Clin Infect Dis. 2005;40:926–931
  19. Ulmer FC. The Hawthorne effect. Educ Dir Dent Aux. 1976;1:28
  20. Pentti J, Syrjala M, Pettila V. Computerized quality assurance of decisions to transfuse blood components to critically ill patients. Acta Anaesthesiol Scand. 2003;47:973–978
  21. Ruchholtz S, Waydhas C, Lewan U, Piepenbrink K, Stolke D, Debatin J, et al. A multidisciplinary quality management system for the early treatment of severely injured patients: implementation and results in two trauma centers. Intens Care Med. 2002;28:1395–1404
  22. Kaplan HS, Battles JB, Van der Schaaf TW, Shea CE, Mercer SQ. Identification and classification of the causes of events in transfusion medicine. Transfusion. 1998;38:1071–1081
  23. Carden R, DelliFraine JL. An examination of hospital satisfaction with blood suppliers. Transfusion. 2004;44:1648–1655

PII: S1473-0502(06)00111-X

doi: 10.1016/j.transci.2006.06.001

Transfusion and Apheresis Science
Volume 35, Issue 2 , Pages 125-130 , October 2006

Article Tools

* Image Usage & Resolution