Blood Transfusion Events
Conditions
Keywords
blood transfusion, adverse event, incident reporting
Brief summary
Inhospital the blood transfusion process consists of many phases: ordering the blood product, analysis of the blood sample, delivery, transport and storage of the blood product and administration. In each of these phases (near) accidents may occur. A severe transfusion incident refers to the transfusion of a wrong blood product, whereas a near miss is detected before transfusion. In 2010 the University Hospitals Leuven introduced a new electronic patient incident report system for transfusion events. In this study the investigators will analyze the reported blood transfusion events to detect the most common causes of blood transfusion events and the weakest link in the blood transfusion chain.
Detailed description
A retrospective survey will be conducted of all transfusion events reported in the University Hospitals Leuven between January 2011 and July 2012. Both severe accidents and near misses will be included. Data will be drawn from the incident report system. Data concerning the number of transfused blood products will be required from the Medical Administration Service. Events will be classified according to the severity and the cause of the event. The different settings where the events took place will be compared using a chi-square test (p\<0,05).
Interventions
None listed
Sponsors
Universitaire Ziekenhuizen KU Leuven
Study design
Time perspective
RETROSPECTIVE
Eligibility
Sex/Gender
ALL
Healthy volunteers
No
Inclusion criteria
* all transfusion events reported in the University Hospitals Leuven between January 2011 and July 2012 * Both severe accidents and near misses were included
Exclusion criteria
* Transfusion reactions
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Severity of inhospital blood transfusion events | up to 1,5 years | included events will be classified into near misses or severe incidents |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Causes of inhospital blood transfusion events | up to 1,5 years | Events are classified into human error, technical problems, deficiency of the blood product and others. Events will also be classified considering the phase in the blood transfusion process. Causes will be studied hospital wide and per setting were the event took place. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Incidence of inhospital blood transfusion events | up to 1,5 years | The number of transfusion events divided by the total number of transfused blood products in the study period |
| Is there a relation between misidentification events and the setting where the event took place? | up to 1,5 years | The different settings where the events took place will be compared using a chi-square test (p\<0,05). |
Countries
Belgium
Outcome results
None listed