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. 2024 Apr;64(4):627-637.
doi: 10.1111/trf.17775. Epub 2024 Mar 12.

Transfusion-related errors and associated adverse reactions and blood product wastage as reported to the National Healthcare Safety Network Hemovigilance Module, 2014-2022

Joel L Chavez Ortiz  1   2 , Isabel Griffin  1 , Sophia V Kazakova  1 , Phylicia B Stewart  1   3 , Ian Kracalik  1 , Sridhar V Basavaraju  1
Affiliations

Transfusion-related errors and associated adverse reactions and blood product wastage as reported to the National Healthcare Safety Network Hemovigilance Module, 2014-2022

Joel L Chavez Ortiz et al. Transfusion. 2024 Apr.

Abstract

Background: Transfusion-related errors are largely preventable but may lead to blood product wastage and adverse reactions, resulting in patient harm. In the United States, the incidence of transfusion-related errors is poorly understood nationally. We used data from the National Healthcare Safety Network (NHSN) Hemovigilance Module to describe and quantify transfusion-related errors, as well as associated transfusion-related adverse reactions and blood product wastage.

Methods: During 2014-2022, data from the NHSN Hemovigilance Module were used to analyze errors, including near misses (errors with no transfusion), incidents (errors with transfusion), and associated serious adverse reactions (severe, life-threatening, or death).

Results: During 2014-2022, 80 acute care facilities (75 adult; 5 pediatric) reported 63,900 errors. Most errors occurred during patient blood sample collection (21,761, 34.1%) and blood sample handling (16,277, 25.5%). Less than one-fifth of reported errors (9822, 15.4%) had a completed incident form. Of those, 8780 (89.3%) were near misses and 1042 (10.7%) incidents. More than a third of near misses (3363, 38.3%) were associated with a discarded blood product, resulting in 4862 discarded components. Overall, 87 adverse reactions were associated with errors; six (7%) were serious.

Conclusions: Over half of the transfusion-related errors reported to the Hemovigilance Module occurred during blood sample collection or sample handling. Some serious adverse reactions identified were associated with errors, suggesting that additional safety interventions may be beneficial. Increased participation in the Hemovigilance Module could enhance generalizability and further inform policy development regarding error prevention.

Keywords: biovigilance; blood wastage; hemovigilance; transfusion incidents; transfusion‐related errors.

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Conflict of interest statement

CONFLICT OF INTEREST STATEMENT

The authors have disclosed no conflicts of interest.

Figures

FIGURE 1
FIGURE 1
Flow diagram of facility participation and inclusion analysis of transfusion-related errors reported to the National Healthcare Safety Network Hemovigilance Module, United States, 2014–2022.
FIGURE 2
FIGURE 2
Most reported error code per error category, National Healthcare Safety Network Hemovigilance Module, United States, 2014–2022.
See this image and copyright information in PMC

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