Three years of haemovigilance in a general university hospital.
The aim of this study is to describe a newly implemented haemovigilance system in a general university hospital. We present a series of short cases, highlighting particular aspects of the reports, and an overview of all reported incidents between 1999 and 2001. Incidents related to transfusion of blood products were reported by the clinicians using a standard preformatted form, giving a synopsis of the incident. After analysis, we distinguished, on the one hand, transfusion reactions, that are transfusions which engendered signs or symptoms, and, on the other hand, the incidents where management errors and/or dysfunctions took place. Over 3 years, 233 incidents were reported, corresponding to 4.2 events for 1000 blood products delivered. Of the 233, 198 (85%) were acute transfusion reactions and 35 (15%) were management errors and/or dysfunctions. Platelet units gave rise to statistically (P < 0.001) more transfusion reactions (10.7 per thousand ) than red blood cells (3.5 per thousand ) and fresh frozen plasma (0.8 per thousand ), particularly febrile nonhaemolytic transfusion reactions and allergic reactions. A detailed analysis of some of the transfusion incident reports revealed complex deviations and/or failures of the procedures in place in the hospital, allowing the implementation of corrective and preventive measures. Thus, the haemovigilance system in place in the 'Centre Hospitalier Universitaire Vaudois, CHUV' appears to constitute an excellent instrument for monitoring the security of blood transfusion.
Michlig
C
C
Service Régional Vaudois de Transfusion Sanguine, CHUV, Lausanne, Switzerland.
Vu
D-H
DH
Wasserfallen
J-B
JB
Spahn
D R
DR
Schneider
P
P
Tissot
J-D
JD
D000368:Aged; D000369:Aged, 80 and over; D001771:Blood Banks / Q000592:standards*; D001787:Blood Group Incompatibility; D001803:Blood Transfusion / Q000592:standards; D002648:Child; D005260:Female; D005334:Fever / Q000209:etiology; D006785:Hospitals, University / Q000592:standards*; D006801:Humans; D008297:Male; D019300:Medical Errors; D008875:Middle Aged; D011785:Quality Assurance, Health Care; D012308:Risk Management / Q000592:standards* / Q000706:statistics & numerical data; D013557:Switzerland; D013597:Systems Analysis; D065227:Transfusion Reaction