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A survey of blood transfusion errors in Aichi Prefecture in Japan: Identifying major lapses threatening the safety of transfusion recipients

  • Masaki Ri
    Correspondence
    Correspondence author at: Department of Blood Transfusion and Cell Therapy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-chou, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan.
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Department of Blood Transfusion and Cell Therapy, Nagoya City University Hospital, Nagoya, Japan
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  • Masanobu Kasai
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Department of Hematology and Oncology, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
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  • Akio Kohno
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Department of Hematology and Oncology, Konan Kosei Hospital, Konan, Japan
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  • Masaru Kondo
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Okazaki City Hospital, Okazaki, Japan
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  • Masashi Sawa
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
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  • Tomohiro Kinoshita
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Japanese Red Cross Aichi Blood Center, Seto, Japan
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  • Isamu Sugiura
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Blood Transfusion and Cell Therapy Center, Toyohashi Municipal Hospital, Toyohashi, Japan
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  • Yasuo Miura
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Department of Transfusion Medicine and Cell Therapy, Fujita Health University Hospital, Toyoake, Japan
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  • Kazuhito Yamamoto
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Department of Hematology and Cell Therapy, Aichi Cancer Center Hospital, Nagoya, Japan
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  • Toshiki I. Saito
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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  • Yukiyasu Ozawa
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Department of Hematology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
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  • Tadashi Matsushita
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
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  • Hidefumi Kato
    Affiliations
    Aichi Prefectural Joint Committee of Blood Transfusion Therapy, Nagoya, Japan

    Department of Transfusion Medicine, Aichi Medical University Hospital, Nagakute, Japan
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Open AccessPublished:January 27, 2020DOI:https://doi.org/10.1016/j.transci.2020.102735

      Abstract

      Background

      Despite recent progress in blood systems, transfusion errors can occur at any time from the moment of collection through to the transfusion of blood and blood products. This study investigated the actual statuses of blood transfusion errors at institutions of all sizes in Aichi prefecture.

      Materials and methods

      We investigated 104 institutions that perform 98 % of the blood transfusions in Aichi prefecture, and investigated the errors (incidents/accidents) that occurred at these facilities over 6 months (April to September, 2017). Incident/accident data were collected from responses to questionnaires sent to each institution; these were classified according to the categories and risk levels.

      Results

      Ninety-seven of the 104 institutions (93.3 %) responded to the questionnaire; a total of 688 incidents/accidents were reported. Most (682 cases; 99.2 %), were classified as risk level 2; however, 6 were level 3 and over, which included problems with autologous transfusion and inventory control. Approximately one-half of the incidents/accidents (394 cases; 57.3 %), were related to verification and the actual administration of blood products at the bedside; more than half of these incidents/accidents occurred at large-volume institutions. Meanwhile, a high frequency of incidents/accidents related to transfusion examination and labeling of blood products was observed at small- or medium-sized institutions. The reasons for most of these errors were simple mistakes and carelessness by the medical staff.

      Conclusions

      Our results emphasize the importance of education, operational training, and compliance instruction for all members of the medical staff despite advances in electronic devices meant to streamline transfusion procedures.

      Keywords

      1. Introduction

      Transfusion of blood is widely performed supportive therapy for patients with active or chronic bleeding, surgical stress, or hematological disorders. In Japan, blood transfusions are routinely conducted across medical institutions, including large hospitals and small clinics. However, inappropriate management of a blood transfusion carries a high risk of causing a life-threating accident in a recipient. Policies and guidelines related to blood transfusions have been established by the Ministry of Health, Labor, and Welfare (MHLW) of Japan [
      • Handa M.
      Safer and more appropriate blood transfusion therapy.
      ,
      Research on regulatory science of pharmaceuticals and medical devices study on transfusion reaction monitoring system in medical institutions. Practical guide for safe hospital blood transfusion. The japan society of transfusion medicine and cell therapy.
      ], and used as a reference for the blood transfusion treatment system in each hospital. These guidelines include two scopes, the safety procedures of transfusion medicine and the appropriate use of blood products, thereby focusing on the prevention of side effects triggered by immature blood transfusion systems. These guidelines also recommend the use of blood products based on clinical evidence and transfusion triggers for each disease, such as active or chronic bleeding and hematological disorders, and have wide acceptance in most of the institutions handling blood transfusions. In the last decade, due to the establishment of policies and guidelines, the approach to transfusion-related adverse events have improved, and serious mistransfusions, such as ABO-incompatible transfusion and patient identification errors, have been reduced with the aid of advanced information technology. However, human errors of any dimension in transfusions, reported as incidents and accidents, have neither been reduced considerably nor have shown any improvement so far. To reduce transfusion errors, a practical guide for safe hospital blood transfusions was additionally issued by the Japanese society of blood transfusion and cell therapy under supervision of the MHLW [
      • Makino S.
      Transfusion medicine in practice.
      ]. However, ignorance or poor understanding of the transfusion system among the medical staff having less experience with transfusions may be a critical factor for the generation of transfusion errors, even though practical and detailed guidelines have been established. In addition, the diversity of patient volumes and specialties across these institutions results in disparate incidence or accident rates among them. Therefore, to eliminate errors and improve the safety of blood transfusions, it is necessary to surveil these institution to document any incidents and accidents that occur in order to learn how to prevent them more effectively [
      • Hensley N.B.
      • Koch C.G.
      • Pronovost P.J.
      • et al.
      Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.
      ,
      • Strauss R.
      • Downie H.
      • Wilson A.
      • et al.
      Sample collection and sample handling errors submitted to the transfusion error surveillance system, 2006 to 2015.
      ].
      Owing to advancing technologies, the automation and computerization of blood transfusion procedures have the potential to reduce clerical errors. Using barcode-based coupling of the patient’s ID band with blood product labels, as well as radiofrequency identification (RFID), human error rates have been dramatically reduced. However, costs, security, and privacy appear to be the principal barriers to the adoption of these advanced technologies at many institutions [
      • Coustasse A.
      • Cunningham B.
      • Deslich S.
      • Willson E.
      • Meadows P.
      Benefits and barriers of implementation and utilization of radio-frequency identification (RFID) systems in transfusion medicine.
      ], especially small-sized facilities. Moreover, no system has been developed that can completely eliminate the incidences of human error to date, as even technologies such as RFID are not fool-proof [
      • Clifford S.P.
      • Mick P.B.
      • Derhake B.M.
      A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change.
      ,
      • Heddle N.M.
      • Fung M.
      • Hervig T.
      • et al.
      Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).
      ,
      • Nuttall G.A.
      • Stubbs J.R.
      • Oliver Jr., W.C.
      Transfusion errors: causes, incidence, and strategies for prevention.
      ].
      To ensure the safety of transfusion medicine in Aichi prefecture in Japan, we previously selected 12 major medical institutions that perform abundant blood transfusions, and performed a preliminary analysis of the incidents and accidents reported by these facilities over 6 months in 2016. Our analysis revealed that such incidents/accidents all occurred during the process of blood transfusion, from ordering the blood product to actual infusion by the bedside. The occurrence of these incidents was considered to be due to an insufficient understanding of the operative norms and systems required, as well as careless mistakes by the medical staff at all levels at each institution.
      In the current study, we performed an expanded survey of transfusion related incidents that occurred across the entire prefecture of Aichi, analyzed their causes, and identified effective methods to prevent human errors and enhance the safety of transfusion medicine in the era of highly advanced electronic devices.

      2. Materials and methods

      We performed a retrospective review of transfusion-related events covering the period between April and September, 2017. A total of 104 medical institutes that collectively perform 98 % of all blood transfusions in Aichi prefecture were sent questionnaires to inquire about both their specific transfusion procedures and any related incidents or accidents. This questionnaire collected 5 key pieces of information including the number of blood products actually transfused, type of transfusion error, number of incidents/accidents that occurred during the surveillance period, impact of the transfusion incident/accident on the recipient, and cause of the incident/accident (supplemental data 1).
      Transfusion related incidents/accidents were classified into categories and risk levels according to the guidelines proposed by the MHLW study group ‘Research of the Side Effects of Transfusions’ (Table 1). Risk assessments for each incident or accident were determined based on the impact on the recipient. As shown in Table 2, events of levels 0–3a were defined as incidents, whereas events of levels 3b and over were defined as accidents that required continuous treatment owing to ensuing illnesses or injuries.
      Table 1Classifications of blood transfusion incidents/accidents.
      Categories
      1Ordering pre-transfusion testing
      2Handling labels and collection of specimens
      3Performance of transfusion-related testing
      4Transferring the results of transfusion-related testing
      5Decision to administer blood products and ordering
      6Ordering blood products from the Japanese Red Cross Society
      7Receiving the blood product and irradiation
      8Handling and storing the blood products at the blood transfusion unit
      9Delivering the blood product to the inpatient ward
      10Handling of the blood product at the inpatient ward
      11Preparation and confirmation of the blood transfusion just before the procedure
      12Transfusion of blood products in a bed side
      13Implementation record of transfusion, mainly by electronic device
      14Returning the products
      15Inventory control
      16Self-donated products
      17Stem cell transplantation and cell therapy
      Table 2Definitions of blood transfusion incident/accident risk levels.
      LevelDescription
      IncidentLevel 0Found and corrected a mistake that risked incorrect handling
      Level 1No consequences for the patient owing to the incident
      Level 2Patient experienced incident-related consequences that did not require treatment
      Level 3aAny serious changes requiring transient treatment owing to the accident
      AccidentLevel 3bAny serious changes owing to the accident that required continuous treatment
      Level 4aAny serious changes owing to the accident that required long-term treatment
      Level 4bAny serious changes that caused subsequent complications because of the accident
      Level 5Death due to the accident

      2.1 Statistical analysis

      Linear regression analysis was performed to estimate the relationship between the number of blood products and the events per institution.

      3. Results

      3.1 Total number of supplied blood products and transfusion errors

      Of the 104 institutions surveyed, 97 (93.3 %) responded to the questionnaire; the sizes of the responding facilities are summarized in Fig. 1a. Among the 97 institutions that participated, 42.3 % were small-scale (20–299 beds), 28.9 % were median-scale (300–499 beds), and 25.8 % were large-scale (≥500 beds). The total number of blood products administrated in these 97 institutions during the survey period was 118,206, including 75,347 red blood cell products, 20,735 platelet products, 17,941 fresh frozen plasma products, and 4183 whole-blood products for autotransfusion. A total of 688 incidents and accidents were reported during the survey period, with an event rate of 0.58 %. In linear regression analysis between the number of blood products and the incidences of transfusion (supplemental data 2), only a poor-to-moderate correlation was observed (R2 = 0.406; p < 0.0001).
      Fig. 1
      Fig. 1Types of institutions enrolled in this study and classification of transfusion incidents/accidents. (a) The sizes of the 97 institutions enrolled in this study. (b) Numbers and percentages of transfusion incidents/accidents in each category.

      3.2 Numbers and contexts of transfusion errors at each risk level

      All 688 incidents/accidents were categorized according to the stages in which they occurred (Fig. 1b). The highest incidences of these events occurred during implementation/recording at the bedside (category 13), transfusion of blood products at the bedside (category 12), and preparation and verification of blood transfusion (category 11), at 23.3 % (160 events), 17.4 % (120 events), and 16.6 % (114 events), respectively. These 3 categories, which mainly involved checking and implementing the blood transfusion procedure at the bedside, accounted for half of all the incidents/accidents. Representative examples of such incidents or accidents in each category are shown in Table 3.
      Table 3Representative cases of incidents/accidents from the error 3 categories that occurred most frequently.
      CategoryRepresentative case
      11Lack of informed consent for transfusion
      Lack of confirmation just before administering the product, such as coupling the patient’s ID band with the blood product label
      Wrong setting of the speed of the administration
      12Forgetting to administer the blood product at a planned time or date.
      A root error resulting in mixing the blood product with other drugs
      Administration of the wrong blood product volume
      13Forgetting to record the administered blood product
      Recording the ID of an unused product
      No observation or recording of side effects following blood transfusion
      The breakdown of all 688 incidents/accidents category-wise is seen in Fig. 2a. As seen in Table 4, there were six events of level 3 and higher including 2 cases related to handling transfusions at the bedside (category 12), 2 related to autologous transfusion (category 16), 1 involving inventory control (category 15), and 1 involving internal handling (category 10). In 2 cases, autologous blood samples were spoiled owing to incorrect handling of the storage bag, and spoilage of a cord blood stem cell product also occurred because of inefficient handling of the refrigerator. Incidents or accidents occurred across all stages of blood transfusion, and the main reasons for their occurrence were either a poor understanding of (or insufficient compliance with) operational procedures, insufficient collaboration between the medical staff, and human errors attributable to work fatigue.
      Fig. 2
      Fig. 2Classification of transfusion incidents/accidents according to risk level and category. (a) The numbers of incidents/accidents in each risk level. (b) & (c) Populations that experienced incidents/accidents of categories 1–4, categories 11–13, and other categorizes per size of facility.
      Table 4Cases of error category level 3 and higher.
      CategoryLevelCase
      103aBlood products sent from blood transfusion unit to the ward were missing resulting in worsening of anemia in the patient.
      123aAdministration of multiple blood products within a short period without planned interval between the products, resulting in heart failure of the patient due to overdose.
      3aMissed observation of the patient with history of transfusion allergy during administration of blood product, resulting in worsening of the transfusion allergy and the need for intensive medication.
      153bMissed closing the lid of liquid nitrogen freezer used for preservation of cord blood stem cells, resulting in spoiled cord blood cells. This accident resulted in termination of allogeneic stem cell transplantation and subsequent progression of the hematological disease in the patient.
      163aSpoiled autologous blood samples just before the transfusion due to incorrect handling of the storage bag in the postoperative patient. Emergency transfusion was performed.
      3aExcessive blood collection from the patient for autologous blood transfusion due to missing confirmation of planned volume, leading to the development of vasovagal reaction and the need for medication.
      Finally, we analyzed the categories of incidents/accident as a function of institution size (Fig. 2b and c). Among all groups, a high incidence of category 11–13 errors was observed (62.4 %, 46.9 %, and 48.0 % in large-, medium, and small-sized institutions, respectively; Fig. 2c). However, when focusing on the early processes of blood transfusions (categories 1–4), small- and medium-sized institutions showed higher incident rates (17.9 % and 13.3 %, respectively); large-sized institutions had a rate of 8.6 %.

      4. Discussion

      In our study, responses to the questionnaires were obtained from most of the institutions that perform blood transfusions in Aichi prefecture. Therefore, our retrospective study includes almost all cases of transfusion errors that occurred across institutions of all sizes, and may thus provide actionable data that can be used to prevent future transfusion errors.
      A total of 688 transfusion-related incidents/accidents occurred over 6 months in Aichi prefecture; as such, the rate of incidents/accidents was 0.58 %. This rate was relatively higher than those found in 2 previous studies conducted in Japan, including a survey of incidents/accidents at 12 major institutions in Aichi prefecture (0.38 %) and a 7-year survey of a single institute (0.51 %) [
      • Sato Y.
      • Niwa Y.
      • Takahama H.
      • Asazuma N.
      • Murata Y.
      • Sunouchi K.
      Incidents associated with blood transfusion in Kawakita General Hospital-Seven years’ experience.
      ]. Unlike these previous studies, ours included a high number of small- or medium-sized institutions; these showed rates of incidents/accidents per transfused blood sample (1.16 % and 0.56 %, respectively), which were higher than the rates observed in large-sized facilities. Among all the processes related to blood transfusion procedures, those involving pre-transfusion tests (categories 1–4) showed a lower frequency of incidents/accidents than did other processes. However, a relatively high rate of incidents during pre-transfusion testing was observed in small- or medium-sized institutions, indicating the lack of a well-constructed system or inexperience in handling pre-transfusion testing in such facilities. The establishment of a well-planned system that takes into account the characteristics and size of each individual facility is required to ensure patient safety during pre-transfusion testing [
      • Coustasse A.
      • Cunningham B.
      • Deslich S.
      • Willson E.
      • Meadows P.
      Benefits and barriers of implementation and utilization of radio-frequency identification (RFID) systems in transfusion medicine.
      ].
      Consistent with previous reports [
      • Bolton-Maggs P.H.B.
      Serious hazards of transfusion - conference report: celebration of 20 years of UK haemovigilance.
      ,
      • Baele P.L.
      • De Bruyere M.
      • Deneys V.
      • et al.
      Bedside transfusion errors. A prospective survey by the Belgium SAnGUIS Group.
      ], approximately one-half of the incidences/accidents observed in our study were from categories 11–13, which involved bedside procedures. Therefore, retraining of personnel for proper compliance with transfusion procedures, especially physicians and nurses, is needed to reduce bedside errors. Several errors related to the recording of administered blood products (category 13), such as documenting unused blood samples, neglecting to record transfusion-related side effects, and forgetting to document the transfusion altogether, were observed. Although the development of electronic equipment enables the establishment of well-planned blood transfusion procedures, human errors still occur [
      • Coustasse A.
      • Cunningham B.
      • Deslich S.
      • Willson E.
      • Meadows P.
      Benefits and barriers of implementation and utilization of radio-frequency identification (RFID) systems in transfusion medicine.
      ,
      • Nuttall G.A.
      • Stubbs J.R.
      • Oliver Jr., W.C.
      Transfusion errors: causes, incidence, and strategies for prevention.
      ,
      • Mounchili A.
      • Leduc S.
      • Archibald C.
      • Miller J.
      • Hyson C.
      A summary of the transfusion error surveillance system: 2008–2011.
      ]. To prevent this, training of the medical staff to comply with transfusion procedures should be prioritized [
      • Bolton-Maggs P.H.B.
      Serious hazards of transfusion - conference report: celebration of 20 years of UK haemovigilance.
      ,
      • Myhre B.A.
      • McRuer D.
      Human error - A significant cause of transfusion mortality.
      ].
      In our study, the main causes of incidents/accidents were attributed to simple mistakes such as the lack of documentation or carelessness. Transfusion-related errors can be serious in nature, such as when incompatible blood is administered. Excess dependence on electronic devices may also trigger human errors and/or prevent their early detection; therefore, essential preventive precautions, compliance with operating procedures, and verifying that the blood product matches the intended recipient at the bedside should all be emphasized via educational or retraining programs targeting the medical staff. In most academic institutions, lectures on transfusion medicine and practical examinations on transfusion-related training are conducted for both the undergraduate and graduate students; however, in Japan, no systematic evaluation of comprehension and attainment of transfusion procedures in students are conducted before they begin working. Therefore, to reduce errors caused by lack of knowledge and experience among the medical staff, well-planned training and pre-work evaluation of the performance of the transfusion procedure should be conducted.
      With respect to the risk level of incidents/accidents, most cases were assessed as levels 0–2, suggesting that the risk to the patients’ safety was minimal. However, level 3 events occurred in 6 cases, among which 5 transpired in large-sized institutions. These included 1 event related to the handling of a blood product at an inpatient ward (category 10), 2 events related to errors at bed side (category 12), 1 event related to the inefficient handling of a refrigerator (category 15), and 2 events related to autologous transfusion (category 16). Among them, two serious incidents occurred at a bed side (category 12), a heart failure due to an overdose of blood products, and worsening of a transfusion allergy in a patient with a history of transfusion allergy, that could have been prevented if multiple checks had been conducted by the staff. While administering two or more blood products, the planned interval between the products and the dosing rate of administration should be carefully confirmed before the start of the procedure. In addition, history of side effects and allergy related to transfusion in the patient should be shared and re-confirmed by the staff. Lacking confirmation of these fundamental matters is likely to trigger other serious malpractices, and therefore should be corrected by re-training the medical staff and re-confirming the checking procedure. In case of the spoiled cord blood (level 3b, category 16), a simple mistake of forgetting to close the lid of the refrigerator caused a serious consequence of cancellation of the allogenic transplantation and subsequent worsening of the hematological disorder. The reason for this error may be the lack of experience of the staff handling the liquid nitrogen tank, and inadequate setting of the temperature monitoring system. In Japan, stem cell transplantations are performed even in small-sized institutions, and the employment of specialized technical staff for transfusion and cell therapy has been insufficient in most of the institutions. Therefore, further improvement in handling the preservation of blood and cell products and preserving the quality of these products is required to avoid serious errors and secure the safety of the transfusion recipients.
      Recent advantages of the risk management system has encouraged all the staff in healthcare institutions to voluntarily report medical adverse events, incidents and accidents, promptly. Most medium- to large-sized institutions have formed a medical safety committee with a safety manager for each department, to collect and evaluate all the incidents/accidents occurring in the institution. Reporting of critical incidents can provide an important learning effect from the errors as it helps to unmask potentially critical weak points. In Japan, most of the institutions handling blood transfusions hold a conference for the safety managers and Transfusion Therapy Committee once a month, to evaluate all the events related to transfusion errors, and submit a report of the transfusion errors to the regional bureau of health and welfare. Recently, several large institutions have developed computerized incident reporting, which can detect preventable events from the medical records, and operate the critical incident reporting system (CIRS) uniquely. However, these systems have been introduced in limited institutions, mainly large-sized institutions, and no data are available on how the CIRS is used within the healthcare facilities in Japan. CIRS can be regarded as a helpful and supportive tool in clinical risk management. Sharing all transfusion errors among the institutions by a well-established CIRS is desirable to support organizational learning and collective knowledge management.
      As a limitation of our study, transfusion errors were retrospectively analyzed, and replies in the questionnaire may be subject to recall or other biases. In addition, our study had several other issues that required improvement: the number of institutions investigated was small, duration of the investigation period was limited, and there was a lack of critical content related to each incident/accident, such as the kind of medical staff responsible for the incident/accident and the adequacy assessment of the blood transfusion training pathway at each institution. A well-planned prospective survey is desirable to resolve the bias and elucidate the fundamental issues triggering blood transfusion errors at each institution more accurately.
      Results of the current study were reported to the Aichi Prefectural Joint Committee of Blood Transfusion Therapy. After evaluation and approval by the committee, these results were posted on the homepage of the regional bureau of health and welfare in Aichi prefecture, and also sent to all the institutions handling blood transfusions. Several institutions adopted the results of the current study to educate and train all the medical staff handling blood transfusions. In addition, a survey of the transfusion system and related problems in small-sized institutions and home medical care centers such as clinics has now been proposed based on the result of our study, which will be conducted by the Aichi Prefectural Joint Committee of Blood Transfusion Therapy.
      In conclusion, errors were observed during all stages of the blood transfusion process, mainly during the confirmation, handling, and documenting of transfusions by the bedside. Most were simple mistakes committed by the medical staff. Education, training, and assuring compliance with proper transfusion procedures for all the involved personnel should be prioritized to prevent such human errors and ensure the safety of transfusion medicine.

      Authorship contributions

      Study conception and design: T.M., H.K.
      Acquisition, analysis, and interpretation of data: M.R., M.K, A.K., M.K., M.S., T.K., I.S., Y.M., K.Y., T.I.S., Y.O., M.T., H.K.
      Drafting of manuscript: M.R., H.K,
      All Authors reviewed and edited the manuscript.

      Declaration of Competing Interest

      None of the Authors has a conflict of interest with any of the subject matter of this work.

      Acknowledgements

      We thank all institutions in Aichi Prefecture that participated in the survey for transfusion errors.

      Appendix A. Supplementary data

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