Experience with the medical event reporting system for transfusion medicine (MERS-TM) at three hospitals.
BACKGROUND
The MERS-TM assists hospital transfusion services to identify, analyze, and correct system events relating to the delivery of blood to patients.


METHODS
The MERS-TM system was used from February of 1999 to December 2002. All reported near-miss and actual events were recorded and analyzed.


RESULTS
During these 47 months, 4670 events were reported by the transfusion service. Of these events, 94% were classified as a near-miss event and 93% were detected before the blood product was administered. No ABO-incompatible transfusions were detected despite transfusion of 50,137 units of red blood cells. High severity events with the potential for patient harm accounted for 241 (5%) of the 4670 events. Nursing related events accounted for 188 (78%) of the high severity events. In one out of 4430 (0.023%) samples tested, a high severity sample-testing event was detected. In one out of 1550 (0.06%) samples collected, a high severity sample-collection event was detected.


CONCLUSIONS
An event reporting system is essential if one is to determine where and how often events are occurring within the transfusion process.
Callum
Jeannie L
JL
Department of Clinical Pathology, Sunnybrook and Women's College Health Sciences Centre, and The University of Toronto, 2075 Bayview Avenue, Toronto, Ont., Canada. jeannie.callum@sw.ca
Merkley
Lisa L
LL
Coovadia
Ahmed S
AS
Lima
Ana P
AP
Kaplan
Harold S
HS
D001803:Blood Transfusion / Q000592:standards*; D003625:Data Collection; D003628:Database Management Systems / Q000706:statistics & numerical data; D006801:Humans; D019300:Medical Errors / Q000145:classification* / Q000517:prevention & control / Q000706:statistics & numerical data; D008505:Medical Staff, Hospital / Q000193:education / Q000592:standards*; D009864:Ontario; D012308:Risk Management / Q000379:methods* / Q000706:statistics & numerical data; D012449:Safety; D065227:Transfusion Reaction