[Reports of transfusion incidents: experiences from the first year of hemovigilance in the region of the former ZWN (South West Netherlands) blood bank in Rotterdam].
OBJECTIVE
Itemize blood transfusion incidents in the South-West Netherlands region (about 3.5 million inhabitants), where a regional reporting system for transfusion incidents was introduced in January 2001.


METHODS
Prospective, descriptive.


METHODS
In the period 1 January 2001-31 December 2001, 22 hospitals voluntarily reported transfusion incidents in patients to the blood bank. All incidents were anonymously recorded in a standardised report and registered in 14 categories.


RESULTS
A total of 119 transfusion incidents were reported and categorised as: incorrect blood component transfused (n = 8), mild fever 1-2 degrees C (n = 14), non-haemolytic fever > 2 degrees C (n = 36), acute haemolytic transfusion reactions (n = 3). delayed haemolytic transfusion reactions (n = 18), allergic reactions (n = 11), bacterial contamination (n = 3), transfusion-related acute lung injury (n = 1), near accidents (n = 6) and product recalls (n = 19). There were no reports in the categories anaphylactic shock, post-transfusion purpura, transfusion-acquired viral infection, and transfusion-related graft versus host disease. In the same year of haemovigilance, the blood bank issued a total of 158,000 blood products. A complication rate of 1:700 blood products was calculated. It is estimated that 53% of all incidents were reported.


CONCLUSIONS
Despite all of the safety measures taken, severe adverse events still occurred. A well-run system for haemovigilance can contribute to the knowledge of transfusion incidents. The safety and quality of blood transfusions can be improved if this knowledge is incorporated into ongoing education about blood transfusions and in the prevention and treatment of transfusion reactions.
Beckers
E A
EA
Sanquin Bloedbank regio Zuidwest, locatie Rotterdam, Wytemaweg 10, 3015 CN Rotterdam.
Dinkelaar
R B
RB
te Boekhorst
P A
PA
van Ingen
H E
HE
van Rhenen
D J
DJ
D001771:Blood Banks / Q000592:standards*; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data*; D009426:Netherlands; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D012308:Risk Management; D012449:Safety; D065227:Transfusion Reaction