Transfusion Error Surveillance System (TESS) - 2012-2013 Report

Acknowledgments: The development of the Transfusion Error Surveillance System (TESS) would not have been possible without the collaborative support and continued commitment of the many transfusion safety officers, medical laboratory technologists and other healthcare professionals in hospitals and blood Transfusion Services. Their dedication to reducing errors and increasing patient safety has led to the collection and analysis of 2012-2013 TESS data.

N.B. This document must be cited as the source for any information extracted and used from it.

Suggested citation: Public Health Agency of Canada. Transfusion Error Surveillance System (TESS) - 2012-2013 Report. Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, 2015.

Information to the reader of the Transfusion Error Surveillance System (TESS) 2012-2013 Report

The Centre for Communicable Diseases and Infection Control (CCDIC) of the Public Health Agency of Canada (the Agency) is pleased to present the 2012-2013 Transfusion Error Surveillance System (TESS) Report. This report presents transfusion error surveillance data submitted during 2012 and 2013 by Canadian sentinel hospitals participating in the Transfusion Error Surveillance System (TESS).

The TESS is a voluntary surveillance system established by the Agency to capture non-nominal data on errors occurring at any point in the transfusion chain, including those detected before or after transfusion of blood and blood products to the patient, as well as those that may or may not have resulted in adverse transfusion reactions. The overall goal of the TESS is to identify potential areas for improvement in the transfusion chain and, ultimately, improve transfusion and transfusion safety in Canada.

CCDIC is responsible for the collection, management and analysis of the TESS data, as well as the production of reports summarizing key findings. CCDIC supports the use of these data to inform public health and policy action. In addition, CCDIC supports the Agency's ongoing commitment to improving data quality, and to defining and setting surveillance standards.

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Organization:
Type: Report
Published: 2015-07

Table of Contents

Executive summary

Blood transfusions are an important component of Canada's health care system. Although Canada has one of the safest blood systems in the world, transfusion-related errors can occur at various points in the transfusion chain, which encompasses any point in the collection, labelling, testing, storing, handling, transfusion, etc. of blood components and products and during the collection, labelling, testing, storing and handling of pre-transfusion patient samples. Transfusion-related errors may occur in either clinical or laboratory settings and may result in ABO incompatibilities, administrative delays, product wastage, inappropriate transfusions and the possible need for sample re-collection. Limiting opportunities for transfusion errors is therefore an important aspect of public health safety.

This report offers an analysis of the Transfusion Error Surveillance System (TESS) data reported from 2012 to 2013. Findings are presented for all transfusion-related errors, including errors that were detected prior to blood transfusion as well as errors detected during and after blood transfusion.

The TESS was initiated in 2005 by the Public Health Agency of Canada (the Agency) to monitor errors occurring at any point in the transfusion chain. Currently, 15 hospitals participate in the surveillance as sentinel sites and report all transfusion-related errors to the Agency on a quarterly basis. By tracking transfusion-related errors it is possible to identify not only the the policy and procedure in the transfusion chain where errors most commonly occur, but also the points where changes can be implemented in order to ensure mechanisms are in place to detect errors before transfusion as well as to limit the likelihood for transfusion errors.

Overall, a total number of 17,344 transfusion-related errors were reported from 2012 (n=8,698) to 2013 (n=8,646) and, sample collection (36.2%) and sample handling (14.4%) errors constituted the most frequently reported of all the errors. Highest occurrence rates were recorded by medical/surgical wards (22.1%), emergency rooms (20.9%), Transfusion Services (18.3%), outpatient clinics (11.0%) and intensive care units (11.4%).

The robustness of the detection processes in hospitals participating in the TESS was once again demonstrated through the capturing of over 93% (n=16,193) of the errors before they reached the patients. Detection by the Transfusion Service alone accounted for 93.5% (n=15,140) of these errors also sometimes referred to as "near-miss".

Of the 1,151 errors that reached the patient, approximately 97% (n=1,117) caused no harm. The majority of the remaining 3% (n=34) that caused some harm to the patients were errors related to product request (n=26) and unit transfusion (n=6). These two categories of errors were linked to 22 cases of transfusion-associated circulatory overload (TACO), 6 cases of febrile non-hemolytic reactions, 3 cases of minor allergic reactions and 1 case of IVIG headache. The remaining two errors that resulted in harm to the patients were sample testing and product selection errors which were respectively linked to the development of an acute hemolytic reaction (n=1) and a delayed serologic reaction (n=1).

The TESS data demonstrate that blood transfusions are both safe and efficient in Canadian hospitals participating in the surveillance coordinated by the Agency. Only 0.2% of all transfusion errors reported to the TESS network resulted in harm to patients and none of these cases resulted in death. While these findings may undoubtedly be suggestive of very efficient transfusion error detection processes/ procedures within participating hospitals, they also highlight potential areas for improvement which are the processes from which the errors that escaped detection were generated, most notably, the product request and unit transfusion processes. Similarly, hospitals should regularly revise/update safety and detection processes in place in each of its units/wards, with each unit/ward/service paying particular attention to processes related to errors for which they were the source, but not the detectors.

Data collected through the TESS facilitate the identification and evaluation of preventive measures designed to optimize system efficiency and, most importantly, patient safety. For example, in one participating hospital, the TESS data facilitated the adoption of prospective auditing of all blood requests to ensure compliance with hospital transfusion guidelines for both indication and dose. This demonstrates the importance of surveillance of transfusion-related errors in Canadian hospitals providing transfusion services.

Introduction

Blood transfusions are an important component of Canada's health care system. Each year in Canada, transfusion of blood and blood products, which may be used to treat blood loss following trauma or surgery or to treat people suffering from conditions such as anemia and cancer, result in improved patient health and saving lives. Although the risk of an adverse event following transfusion is low in Canada due to robust precautionary measures, transfusion-related errors can and do occur. These errors may occur at any step along the transfusion chain, from the collection of blood at donor clinics to the transfusion of blood and blood products to the patient in a hospital setting. Transfusion-related errors can therefore occur in either the laboratory or clinical settings and may arise during the collection, labelling, testing, storing, handling or transfusion of blood and blood products. These errors may result in ABO or other antigen incompatibilities, administrative delays in transfusion or procedures, product wastage, inappropriate transfusions and the possible need for sample re-collection. Ultimately, these errors have the potential to impact patient safety and to increase costs incurred by the health care system. Mitigating the risk of transfusion errors is therefore a leading priority for the government of Canada.

Recognizing the importance of transfusion safety in Canada, the Public Health Agency of Canada (the Agency) developed the Transfusion Error Surveillance System (TESS) in 2005. The TESS was designed to monitor the frequency of all types of errors that can occur at any step in the transfusion chain. Initially implemented as a pilot study encompassing 11 hospitals, the TESS has evolved into a voluntary sentinel surveillance system involving 15 hospitals across 4 Canadian provinces and territoriesFootnote 1. The TESS data serves as a complement to data collected through the Transfusion Transmitted Injuries Surveillance System (TTISS) which monitors the incidence of adverse reactions following blood transfusion in Canada (Transfusion Transmitted Injuries Surveillance System: 2006-2012 Report).

Participating hospitals provide data on a quarterly basis using a secure electronic web-based server maintained by the Agency; all data are captured anonymously to promote participation and complete reporting by all sites. In addition to data on transfusion errors, participating hospitals provide the number of blood components received, requested, prepared and issued, as well as the number of samples received and tests performed (by location of service whenever possible) for the purpose of calculating error rates.

The TESS is a unique blood safety surveillance system in terms of its comprehensiveness; at present, no other surveillance system in the world collects data on all errors occurring throughout the transfusion chain regardless of their potential outcome. However, by identifying the points in the transfusion chain where errors most commonly occur, including those that are detected prior to actual blood transfusion, it is possible to target these areas through corrective action and, ultimately, increase patient safety and reduce system inefficiencies. Following the implementation of measures to minimize opportunities for transfusion errors, the TESS data may be used to determine the efficacy of said measures. Findings may also provide comparable benchmarks for hospitals in Canada regardless of whether they participate or not in the TESS although those not participating will have to adhere to the TESS protocol to ensure validity of data comparisons. The same condition will apply if international comparisons are considered.

Methods

a) Definition

Transfusion errors reported through the TESS are defined as unexpected, unplanned deviations from standard operating procedures or applicable laws and regulations, usually attributable to a human or system problem, that could:

  1. adversely affect the safety, efficacy or quality of blood and blood products (plasma derivatives) as well as the safety of recipients, or/and
  2. result in inefficiencies or cost-ineffective care.

b) Data collection

From 2012 to 2013, data on transfusion-related errors were reported by a core group of 15 hospitals from 4 Canadian provinces/territories: six were of small transfusion capacity (less than 2,000 RBC units per year), five were of medium transfusion capacity (between 2,000 to 10,000 RBC units per year) and four were of large capacity as they transfused more than 10,000 RBC units per year.

Errors are detected within participating hospitals using various methods that include ongoing systematic quality control (chart audit, record review, real-time prospective transfusion audit), scheduled quality assurance, supervisory reports and reporting by any other individual. Since scheduled quality control or supervisory reports are not standardized across the participating hospitals and, their systematic implementation could not be ascertained, errors discovered through these processes were considered for the overall analysis only if they were detected within two days following their occurrence. Those that were discovered more than two days later were analysed separately and are presented in Appendix 1.

The reporting process begins with the individuals who discover the event, whether or not they were involved. Following detection of a transfusion related error at a hospital participating in the TESS, non-nominal data regarding the error are collected by the hospital site. Brief narrative of the error is used to determine the type and code to which the error correspond. This code, as well as other pieces of information such as the date, time and location of the error, the point in the transfusion chain at which the error occurred, the point in the transfusion chain at which the error was detected, and the potential/actual severity of the error and its consequences to the patient, are captured using an online reporting form. The data collected are validated and consolidated into a single file by the Provincial/Territorial Blood Coordinating Office (P/T BCO). The data elements required for the TESS are then extracted and exported to the Public Health Agency of Canada (the Agency) as per the agreement between the participating P/Ts and the Agency. Data exports occur every 3 months. A user's manual for the TESS web application was developed to assist the P/T BCO with the data transfer.

c) Error coding

Transfusion-related errors captured through the TESS are classified using a limited set of predefined, standardized alpha-numeric codes described in detail in the TESS User's manual. The letters in the codes indicate the category within which the error falls (Table 2) and the numeric value differentiates specific errors within each category. For instance all errors described with DC codes are errors that occurred at the level of the distributor/supplier of blood components or blood products; whereas those with UT codes occurred at the time of transfusion: for example, a wrong product/unit transfused to a patient or a wrong patient transfused (Table 2). An example of an error code would be: error coded as a DC 02 is a processing/testing error that occurred at the distributor level, a DC 03 would be a labelling error, etc. Complete listing of the error codes is provided in Appendix 1. Error coding was introduced to enhance the surveillance capabilities as the coding reduces dependence on unstructured narratives which are not made available to the Agency for confidentiality.

To ensure consistency of error coding across Provinces/Territories participating in the TESS, the Agency organises monthly error coding exercises where the P/T BCO staff and reporting sites are invited to discuss complex cases for which error coding may be difficult and may benefit from group discussions which promote standardized reporting. Also, baseline training for error coding is offered to sites aspiring to join the TESS.

The transfusion chain described in Figure 1 indicates where each category of errors occurs. There are errors that occur only in laboratory settings (Transfusion Services, blood suppliers, laboratory services and service providers) or clinical settings (i.e. hospital care units where patients receive transfusion care: operating rooms, emergency rooms, out-patient clinics, intensive care units, obstetrics clinics and units, etc.). Errors related to distributor codes (DC), product check-in (PC), inventory management (IM), unit storage (US), sample receipt (SR), sample testing (ST), product selection (PS), unit manipulation (UM) and unit issue (UI) occur only in laboratory setting while those related to product request (PR), sample collection (SC), request for pick-up (RP) and unit transfusion (UT) only occur in clinical setting (figure 1).

Table 1. General error codes & corresponding denominator data Footnote 2, TESS 2012-2013
Error Description Corresponding denominator
Code Type
DC Distributor codes Errors occurring at the supplier level (including blood manufacturers) Units of product received
PC Product check-in Errors that relate to putting products into inventory from the Blood Centre, another site/campus or return from the ward.
US Unit storage Errors related to incorrect storage of blood products/components within the Transfusion Services
IM Inventory Management Errors related to inventory management
PR Product request Errors related to placing an order/request for a product Units of product requested
SC Sample collection Errors that relate to collecting or labelling specimen tubes Samples received
SH Sample handling Events related to test ordering, sample collection and transportation that do not involve the sample itself.
  • Errors related to managing requisition,
  • Sample transport errors, etc.
SR Sample receipt Errors related to receipt of samples in the laboratory
ST Sample testing Testing errors Tests performed
PS Product selection Production selection errors Units of product prepared
UM Unit manipulation Processing errors (pooling, irradiation, …)
RP Request for pick-up Errors related to picking up blood products/ components for transfusion Units of product issued
UI Unit issued Events occurring during the issue of blood or blood product for transfusion.
  • Wrong product issued,
  • Product issued to wrong patient, etc.
UT Unit transfusion Events occurring outside of the Transfusion Services involving the storage, selection and administration of a blood or blood product.
  • Wrong product administered,
  • Product administered to wrong patient, etc.
MS Miscellaneous Errors not related to any of those listed above (e.g. incomplete/ incorrect patient registration, …) -

d) Potential severity of transfusion error

The potential severity is a measure of the harm that the error may cause to the patient if the error is not detected. High severity level is assigned to errors that have potential to cause serious injury (including fatal outcome), whereas low and medium severity levels are assigned to errors with potential to cause no or minor/transient injury, respectively. The national TESS working group identified errors that by definition are listed in Table 2 as errors of potential high severity.

Table 2: Pre-defined high (potential) severity errors, TESS 2012-2013
Type of error Description Error code
Product request Order for wrong patient PR 01
Sample collection Sample labelled with wrong patient identification SC 01
Not labelled SC 02
Wrong patient collected (not from intended patient) SC 03
Label incomplete/illegible for key patient identifiers (e.g., name, identification, birthdate) SC 07
Armband incorrect/not available SC 10
Sample handling Paperwork and sample ID do not match SH 02
Sample receipt Sample accepted in error SR 01
Sample testing Sample labelled with incorrect accession label ST 05
Sample/test tubes mixed up/mislabelled ST 09
Request for pick-up Request for pick-up on wrong patient RP 01
Unit issue Product issued to wrong patient UI 04
LIS warning overridden (in error or outside SOP) UI 06
Wrong type/dose of product issued to right patient UI 19
Unit transfusion Administered product to wrong patient UT 01
Administered wrong type/dose of product to patient UT 02
Miscellaneous Patient registration incomplete/incorrect MS 03
 
Figure 1. Transfusion chain and types of errors that may occur at each step
Figure 1
Figure 1 - Text description
The transfusion chain starts with Blood suppliers (Canadian Blood Services, Héma- Québec, and hospitals that may serve as suppliers to others) that supply blood products to transfusion services which manage the inventory in hospitals. Requests for products to transfusion services are initiated/placed from various hospital wards by doctors' prescriptions. Upon receipt of these requests, transfusion services determine what blood type is required and prepare the product as per the prescription, then issued it to the requesting ward for infusion. At each level of the processing of the request specific transfusion errors may occur. Errors related to distributor codes (DC) at the supplier level, those related to: product check-in (PC), inventory management (IM), unit storage (US), product request (PR), sample collection (SC) and handling (SH), sample receipt (SR), sample testing (ST), product selection (PS), as well as unit manipulation (UM) and issue (UI) can only occur at the transfusion services level (laboratory setting), while those related to request for pick-up (RP) and unit transfusion (UT) would happen only at the clinical setting (ward) level

e) Case validation

The P/Ts review all transfusion-related errors reported by participating hospitals from their respective jurisdictions before exporting the data to the Agency (via the TESS electronic web-based system), where a second round of review and validation for completeness and accuracy is conducted by an Agency epidemiologist and a clinical advisor.

f) Statistical analysis

For analytical purposes, data received from the P/Ts are extracted from the TESS electronic warehouse and consolidated into a single file in Microsoft Excel, then subjected to a pre-analytical review and validation. The file is once again transferred to another statistical software package (SAS or Stata) for final analysis, which is mainly focused on the:

  • types of errors,
  • occurrence and detection locations and,
  • errors that caused harm to patient.

Rates of occurrence are calculated using corresponding denominator data (as defined in Table 1) and results given per 100,000 units of products received, requested, prepared and issued, or per 100,000 samples received depending on the error type. The number of samples received and tests performed, as well as the number of units of product received, requested, prepared and issued per one error are also calculated.

N.B.

For the calculation of the rate of unit transfusion errors, the denominator used was the total of units of products issued because of the non-availability of the total units of product transfused.

Results

a) Geographical coverage of the TESS

Transfusion Services of the 15 TESS hospitals issued a total of 424,714 units of blood and blood components to their corresponding clinical services (Table 3) in 2012 and 2013. There was a significant decrease in the number of units of products received (12.4%), requested (12.5%), prepared and issued from 2012 to 2013.

Table 3. Total number of blood products received/requested/prepared/issued before transfusion, TESS 2012 - 2013.
Denominator data 2012 2013 Total
Total number of samples received 144,414 136,435 280,849
Total number of tests performed 297,976 270,122 568,098
Products received
a. Blood components 114,636 98,096 212,732
b. Fractionated products 100,948 90,784 191,732
c. Total number of units recieived 215,584 188,880 404,464
Products requested
a. Blood components 125,499 107,582 233,081
b. Fractionated products 102,543 91,826 194,369
c. Total number of units requested 228,042 199,408 427,450
Produit Prepared
a. Blood components 133,729 117,455 251,184
b. Fractionated products 103,893 93,254 197,147
c. Total number of units prepared 237,622 210,709 448,331
Products issued
a. Blood components 122,934 107,548 230,482
b. Fractionated products 102,493 91,739 194,232
c. Total number of units issued 225,427 199,287 424,714
Table 4: Number of samples and blood products recived/requested/prepared/issued to hospitals by transfusion capacity, TESS 2012 – 2013
Denominator data Hospitals of small transfusion capacity
(<2,000 RBC units /year)
Hospitals of medium transfusion capacity
(2000-10,000 RBC units /year)
Hospitals of large transfusion capacity
(>10,000 RBC units/year)
Total
2012 2013 2012 2013 2012 2013 2012 2013
Total number of samples received 7,513 6,607 35,673 35,960 101,228 93,868 144,414 136,435
Total number of

tests performed

7,722 5,593 74,102 68,071 216,152 196,458 297,976 270,122
Total units of

products received

5,623 5,002 69,669 56,512 140,292 127,366 215,584 188,880
Total units of

products requested

4,790 3,880 70,945 57,195 152,307 138,333 228,042 199,408
Total units of

products prepared

3,291 3,162 75,168 61,719 159,163 145,828 237,622 210,709
Total units of

products issued

3,782 3,186 70,795 57,319 150,850 138,782 225,427 199,287

b) Reported transfusion-related errors

Overall, the TESS received reports on 17,344 transfusion-related errors that met the surveillance criteria in 2012 and 2013 from the 15 Canadian hospitals participating in the TESS and, over 80% (n=13,917) of these errors were reported from hospitals of large transfusion capacities (Tables 5 & 6).

Table 5: Summary report of transfusion-related errors from hospitals of various transfusion capacities, TESS 2012 - 2013
Type of error nFootnote * 2012 2013 Total

Footnotes

Footnote 1

Number of hospitals participating in the TESS

Return to footnote * referrer

Hospitals of small transfusion capacity (<2,000 RBC units /year) 6 192 (2.2%) 189 (2.2%) 381 (2.2%)
Hospitals of medium transfusion capacity (2000 - 10,000 RBC units/year) 5 1,653 (19.0%) 1,393 (16.1%) 3,046 (17.6%)
Hospitals of large transfusion capacity (>10,000 RBC units /year) 4 6,853 (78.8%) 7,064 (81.7%) 13,917 (80.2%)
Total 15 8,698 (100%) 8,646 (100%) 17,344 (100%)

Clinical services in which highest proportions of errors occurred included medical/surgical wards 22.1% (n=3,842), emergency rooms 20.9% (n=3,617), intensive care units 11.4% (n=1,970) and outpatient clinics 11.0% (n=1,912). Transfusion Services accounted for 18.3% (n=3,172) of all the errors (Table 9). The most common were errors related to sample collection 36.2% (n=6,278), sample handling 14.4% (n=2,489), unit transfusion 12.7% (n=2,202) and product request 7.5% (n=1,298) regardless of the transfusion capacity of reporting hospitals (Tables 6, 7 & 8)). These errors collectively account for almost 71% of all reported transfusion-related errors (Table 7). Errors that occurred the least included errors related to inventory management (IM), storage (US), product selection (PS) and which occurred respectively at a rate of 1 error per 2,889; 3,111 and 7,231 units of product received or prepared (Table s 7 & 8).

Table 6. Types of transfusion-related errors reported by hospitals participating in the TESS 2012 – 2013
Type of error (code) Hospitals of small transfusion capacity

(<2,000 RBC units /year)

Hospitals of medium transfusion capacity

(2000-10,000 RBC units /year)

Hospitals of large transfusion capacity

(>10,000 RBC units/year)

Overall
2012 2013 2012 2013 2012 2013 2012 2013
Distributor code (DC) 16 (0.2%) 6 (0.07%) 153 (1.8%) 135 (1.6%) 264 (3.0%) 177 (2.0%) 433 (5.0%) 318 (3.7%)
Product check-in (PC) 4 (0.0%) 8 (0.09%) 52 (0.6%) 35 (0.4%) 190 (2.2%) 114 (1.3%) 246 (2.8%) 157 (1.8%)
Unit storage (US) 5 (0.1%) 11 (0.1%) 18 (0.2%) 12 (0.1%) 37 (0.4%) 47 (0.5%) 60 (0.7%) 70 (0.8%)
Inventory management (IM) 1 (0.0%) 5 (0.06%) 19 (0.2%) 14 (0.2%) 57 (0.7%) 44 (0.5%) 77 (0.9%) 63 (0.7%)
Product request (PR) 12 (0.1%) 8 (0.09%) 188 (2.2%) 126 (1.5%) 547 (6.3%) 418 (4.8%) 747 (8.6%) 552 (6.4%)
Request for pick-up (RP) 3 (0.0%) 3 (0.03%) 103 (1.2%) 119 (1.4%) 258 (3.0%) 364 (4.2%) 364 (4.2%) 486 (5.6%)
Product selection (PS) 1 (0.0%) 0 (0.0%) 14 (0.2%) 10 (0.1%) 23 (0.3%) 14 (0.2%) 38 (0.4%) 24 (0.3%)
Unit manipulation (UM) 2 (0.0%) 0 (0.0%) 41 (0.5%) 45 (0.5%) 96 (1.1%) 72 (0.8%) 139 (1.6%) 117 (1.4%)
Unit issue (UI) 2 (0.0%) 5 (0.06%) 51 (0.6%) 47 (0.5%) 71 (0.8%) 171 (2.0%) 124 (1.4%) 223 (2.6%)
Unit transfusion (UT) 17 (0.2%) 10 (0.1%) 343 (3.9%) 324 (3.7%) 805 (9.3%) 703 (8.1%) 1,165 (13.4%) 1,037 (12.0%)
Sample collection (SC) 24 (0.3%) 35 (0.4%) 332 (3.8%) 231 (2.7%) 2,738 (31.5%) 2,918 (33.7%) 3,094 (35.6%) 3,184 (36.8%)
Sample handling (SH) 42 (0.5%) 47 (0.5%) 105 (1.2%) 105 (1.2%) 969 (11.1%) 1,221 (14.1%) 1,116 (12.8%) 1,373 (15.9%)
Sample receipt (SR) 37 (0.4%) 40 (0.5%) 37 (0.4%) 28 (0.3%) 344 (4.0%) 337 (3.9%) 418 (4.8%) 405 (4.7%)
Sample testing (ST) 16 (0.2%) 7 (0.08%) 112 (1.3%) 88 (1.0%) 307 (3.5%) 283 (3.3%) 435 (5.0%) 378 (4.4%)
Miscellaneous (MS) 10 (0.1%) 4 (0.05%) 85 (1.0%) 74 (0.9%) 147 (1.7%) 181 (2.1%) 242 (2.8%) 259 (3%)
Total 192 (2.2%) 189 (2.2%) 1653 (19%) 1,393 (16.1%) 6,853 (78.8%) 7,064 (81.7%) 8,698 (100%) 8,646 (100%)
Table 7. Annual rates of different types of transfusion-related errors reported through the TESS between 2012 & 2013
Type of error (code) 2012 2013 Overall
Freq. % RateFootnote 3 per 100,000 Risk of one errorFootnote 4 Freq. % Rate per 100,000 Risk of one error Freq. % Rate per 100,000 Risk of one error
Distribution code (DC) 433 2.5% 201 1 : 498 318 1.8% 168 1 : 594 751 4.3% 186 1 : 539
Product check-in (PC) 246 1.4% 114 1 : 876 157 0.9% 83 1 : 1,203 403 2.3% 100 1 : 1,004
Unit storage (US) 60 0.3% 28 1 : 3,593 70 0.4% 37 1 : 2,698 130 0.7% 32 1 : 3,111
Inventory management (IM) 77 0.4% 36 1 : 2,800 63 0.4% 33 1 : 2,998 140 0.8% 35 1 : 2,889
Product request (PR) 747 4.3% 328 1 : 305 552 3.2% 277 1 : 361 1,299 7.5% 304 1 : 329
Product selection (PS) 38 0.2% 16 1 : 6,253 24 0.1% 11 1 : 8,780 62 0.4% 14 1 : 7,231
Unit manipulation (UM) 139 0.8% 58 1 : 1,710 117 0.7% 56 1 : 1,801 256 1.5% 57 1 : 1,751
Request for pick-up (RP) 364 2.1% 160 1 : 626 486 2.8% 244 1 : 410 850 4.9% 199 1 : 503
Unit issue (UI) 124 0.7% 55 1 : 1,818 223 1.3% 112 1 : 894 347 2.0% 82 1 : 1,224
Unit transfusion (UT) 1,165 6.7% 517 1 : 193 1,037 6.0% 520 1 : 192 2,202 12.7% 518 1 : 193
Sample collection (SC) 3,094 17.8% 2,142 1 : 47 3,184 18.4% 2,334 1 : 43 6,278 36.2% 2,235 1 : 45
Sample handling (SH) 1,116 6.4% 773 1 : 129 1,373 7.9% 1,006 1 : 99 2,489 14.4% 886 1 : 113
Sample receipt (SR) 418 2.4% 289 1 : 345 405 2.3% 297 1 : 337 823 4.7% 293 1 : 341
Sample Testing (ST) 435 2.5% 146 1 : 685 378 2.2% 140 1 : 715 813 4.7% 143 1 : 699
Miscellaneous (MS) 242 1.4% - - 259 1.5% - - 501 2.9% - -
Total 8,698 50.1% - - 8,646 49.9% - - 17,344 100% - -
Table 8. Rates of different types of transfusion-related errors reported through the TESS by hospitals of various transfusion capacities, TESS 2012 - 2013
Type of error (code) Hospitals of small transfusion capacity
(<2,000 RBC units /year)
Hospitals of medium transfusion capacity
(2000-10,000 RBC units /year)
Hospitals of large transfusion capacity
(>10,000 RBC units/year)
Overall
Frequence
(%)
Rate per 100,000 Risk of one error Frequence
(%)
Rate per 100,000 Risk of one error Frequence
(%)
Rate per 100,000 Risk of one error Frequence
(%)
Rate per 100,000 Risk of one error
Distribution code (DC) 22 (0.1%) 207 1 : 483 288 (1.7%) 228 1 : 438 441 (2.5%) 165 1 : 607 751 (4.3%) 186 1 : 539
Product check-in (PC) 12 (0.1%) 113 1 : 885 87 (0.5%) 69 1 : 1,450 304 (1.8%) 114 1 : 880 403 (2.3%) 100 1 : 1,004
Unit storage (US) 16 (0.1%) 151 1 : 664 30 (0.2%) 24 1 : 4,206 84 (0.5%) 31 1 : 3,186 130 (0.7%) 32 1 : 3,111
Inventory management (IM) 6 (0.0%) 56 1 : 1,771 33 (0.2%) 26 1 : 3,824 101 (0.6%) 38 1 : 2,650 140 (0.8%) 35 1 : 2,889
Product request (PR) 20 (0.1%) 231 1 : 434 314 (1.8%) 245 1 : 408 965 (5.6%) 332 1 : 301 1,299 (7.5%) 304 1 : 329
Product selection (PS) 1 (0.0%) 15 1 : 6,453 24 (0.1%) 18 1 : 5,704 37 (0.2%) 12 1 : 8,243 62 (0.4%) 14 1 : 7,231
Unit manipulation (UM) 2 (0.0%) 31 1 : 3,227 86 (0.5%) 63 1 : 1,592 168 (1.0%) 55 1 : 1,815 256 (1.5%) 57 1 : 1,751
Request for pick-up (RP) 6 (0.0%) 86 1 : 1,161 222 (1.3%) 173 1 : 577 622 (3.6%) 215 1 : 466 850 (4.9%) 200 1 : 500
Unit issue (UI) 7 (0.0%) 100 1 : 995 98 (0.6%) 76 1 : 1,307 242 (1.4%) 84 1 : 1,197 347 (2.0%) 82 1 : 1,224
Unit transfusion (UT) 27 (0.2%) 387 1 : 258 667 (3.8%) 521 1 : 192 1,508 (8.7%) 521 1 : 192 2,202 (12.7%) 518 1 : 193
Sample collection (SC) 59 (0.3%) 418 1 : 239 563 (3.2%) 786 1 : 127 5,656 (32.6%) 2,899 1 : 34 6,278 (36.2%) 2,235 1 : 45
Sample handling (SH) 89 (0.5%) 630 1 : 159 210 (1.2%) 293 1 : 341 2,190 (12.6%) 1,123 1 : 89 2,489 (14.1%) 886 1 : 113
Sample receipt (SR) 77 (0.4%) 545 1 : 183 65 (0.4%) 91 1 : 1,102 681 (3.9%) 349 1 : 286 823 (4.7%) 293 1 : 341
Sample Testing (ST) 23 (0.1%) 173 1 : 579 200 (1.2%) 141 1 : 711 590 (3.4%) 143 1 : 699 813 (4.7%) 143 1 : 699
Miscellaneous (MS) 14 (0.1%) - - 159 (0.9%) - - 328 (1.9%) - - 501 (2.9%) - -
Total 381 (2.2%) - - 3,046 (17.6%) - - 13,917 (80.2%) - - 17,344 (100%) - -
Table 9. Type of transfusion-related error by location of occurrence, TESS 2012-2013.
Type of error (code) Blood Supplier Emergency room Intensive care unit Laboratory service Medical/ Surgical ward Obstetrics unit Operating room Outpatient clinics Supplier/ Service provider Transfusion Service Total

Table 9 footnotes

Table 9 footnote 1

Information about the occurrence location of a PR related error discovered in the medical/surgical ward missing.

Return to table 9 footnote * referrer

Distribution code (DC) 751 (99.7 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 751 (4.3 %)
Product check-in (PC) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 403 (12.7 %) 403 (2.3 %)
Unit storage (US) 0 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 130 (4.1 %) 130 (0.7 %)
Inventory management (IM) 0 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 140 (4.4 %) 140 (0.8 %)
Product request (PR)Footnote * 0 205 (5.7 %) 230 (11.7 %) 0 (0.0 %) 431 (11.2 %) 134 (16.5 %) 89 (8.2 %) 207 (10.8 %) 2 (2.2 %) 0 (0.0 %) 1,298 (7.5%)
Product selection (PS) 0 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 62 (2,0 %) 62 (0.4 %)
Unit manipulation (UM) 0 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 256 (8.1 %) 256 (1.5 %)
Request for pick-up (RP) 0 125 (3.5 %) 279 (14.2 %) 0 (0.0 %) 286 (7.4) 45 (5.6 %) 42 (3.9 %) 55 (2.9 %) 18 (19.4 %) 0 (0.0 %) 850 (4.9 %)
Unit issue (UI) 0 0 (0.0 %) 0 (0.0 %) 4 (4.6 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 347 (10.9 %) 347 (2.0 %)
Unit transfusion (UT) 0 283 (7.8 %) 600 (30.5 %) 0 (0.0 %) 536 (14.0%) 25 (3.1 %) 563 (51.7 %) 191 (10.0 %) 4 (4.3 %) 0,0 % 2,202 (12.7 %)
Sample collection (SC) 0 2406 (66.5 % 549 (27.9 %) 0 (0.0 %) 1 919 (50.0 %) 379 (46.8 %) 245 (22.5 %) 777 (40.6 %) 3 (3.2 %) 0,0 % 6,278 (36.2 %)
Sample handling (SH) 0 570 (15.8 %) 304 (15.4 %) 0 (0.0 %) 639 (16.6 %) 212 (26,2 %) 126 (11.6 %) 628 (32.8 %) 10 (10.,8 %) 0,0 % 2,489 (14.4 %)
Sample receipt (SR) 0 0 (0.0 %) 0 (0.0 %) 24 (27.6 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 799 (25.2 %) 823 (4.7 %)
Sample Testing (ST) 0 0 (0.0 %) 0 (0.0 %) 5 (5.7 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 808 (25.5 %) 813 (4.7 %)
Miscellaneous (MS) 2 (0.3 %) 0.8 % 8 (0.4 %) 58 (66.7 %) 30 (0.8 %) 15 (1.9 %) 23 (2.1 %) 54 (2.8 %) 56 (60.2 %) 227 (7.2 %) 501 (2.9 %)
Total 753 (100 %) 3,617 (100 %) 1,970 (100 %) 87 (100 %) 3,841 (100 %) 810 (100 %) 1,088 (100 %) 1,912 (100 %) 93 (100 %) 3,172(100 %) 17,343 (100 %)

Table 10 highlights the effectiveness of error detection processes in place within each clinical and Transfusion Service. Transfusion Services demonstrated highest efficiency as they were able to detect the vast majority of errors that originated from within (94.4%) and from other services (92.3%).

Table 10. Transfusion-related errors by locations of discovery and occurrence , TESS 2012-2013
Discovery Occurrence
Where error occurred
Blood supplier Emergency Intensive care unit Lab. service Medical/ Surgical ward Obstetrics Operating room Outpatient clincs Supplier/ Service provider Transfusion Service Total

Table 10 footnotes

Table 10 footnote 1

Information about the occurrence location of a PR related error discovered in the medical/surgical ward missing.

Return to Table 10 footnote * referrer

Where error discovered Blood supplier 4 (0.5%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 10 (0.3%) 14 (0.1%)
Emergency 4 (0.5%) 108 (3.0%) 1 (0.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.1%) 1 (1.1%) 10 (0.3%) 125 (0.7%)
Intensive care unit 7 (0.9%) 1 (0.0%) 300 (15.2%) 0 (0.0%) 4 (0.1%) 1 (0.1%) 5 (0.5%) 2 (0.1%) 3 (3.2%) 43 (1.4%) 366 (2.1%)
Laboratory service 2 (0.3%) 4 (0.1%) 3 (0.2%) 4 (4.6%) 4 (0.1%) 0 (0.0%) 0 (0.0%) 4 (0.2%) 0 (0.0%) 0 (0.0%) 21 (0.1%)
Medical/Surgical wardTable 10 footnote * 12 (1.6%) 7 (0.2%) 2 (0.1%) 0 (0.0%) 251 (6.5%) 0 (0.0%) 0 (0.0%) 1 (0.1%) 2 (2.2%) 36 (1.1%) 311 (1.8%)
Obstetrics 0 (0.0%) 0 (0.0%) 1 (0.1%) 0 (0.0%) 0 (0.0%) 12 (1.5%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (0.1%) 16 (0.1%)
Operating room 4 (0.5%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 5 (0.1%) 0 (0.0%) 169 (15.1%) 6 (0.3%) 2 (2.2%) 17 0.5%) 204 (1.2%)
Outpatient clinics 3 (0.4%) 5 (0.1%) 0 (0.0%) 1 (1.1%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 125 (6.5%) 1 (1.1%) 57 (1.8%) 193 (1.1%)
Supplier/Service provider 3 (0.4%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 4 (0.1%) 0 (0.0%) 0 (0.0%) 1 (0.1%) 0 (0.0%) 1 (0.0%) 9 (0.1%)
Transfusion Service 714 (94.8%) 3,491 (96.5%) 1,663 (84.4%) 82 (94.3%) 3,572 (93.0%) 797 (98.4%) 914 (84.0%) 1,772 (92.7%) 84 (90.3%) 2,995 (94.4%) 16,084 (92.7%)
Total 753 (100%) 3,617 (100%) 1,970 (100%) 87 (100%) 3,841 (100%) 810 (100%) 1,088 (100%) 1,912 (100%) 93 (100% ) 3,172 (100%) 17,343 (100%)

c) Potential severity of reported transfusion-related errors

Transfusion-related errors most commonly reported in 2012 and 2013 were of low (n=12,845; 74.1%) potential severity (Tables 11 & 12). Those of medium and high potential severity represented 8.9% (n=1,536) and 17.1% (n=2,963), respectively (Table 12).

Table 11. Potential severity of reported transfusion-related errors , TESS 2012-2013
Type of error (code) Low potential severity Medium potential severity High potential severity Total
Freq. % Freq. % Freq. % Freq. %
Distribution code (DC) 641 3.7% 38 0.2% 72 0.4% 751 4.3%
Product check-in (PC) 376 2.2% 21 0.1% 6 0.0% 403 2.3%
Unit storage (US) 116 0.7% 12 0.1% 2 0.0% 130 0.8%
Inventory management (IM) 124 0.7% 14 0.1% 2 0.0% 140 0.8%
Product request (PR) 452 2.6% 420 2.4% 427 2.5% 1,299 7.5%
Product selection (PS) 17 0.1% 35 0.2% 10 0.1% 62 0.4%
Unit manipulation (UM) 178 1.0% 58 0.3% 20 0.1% 256 1.5%
Request for pick-up (RP) 627 3.6% 73 0.4% 150 0.9% 850 4.9%
Unit issue (UI) 204 1.2% 61 0.4% 82 0.5% 347 2.0%
Unit transfusion (UT) 1,923 11.1% 222 1.3% 57 0.3% 2,202 12.7%
Sample collection (SC) 5,091 29.4% 70 0.4% 1,117 6.4% 6,278 36.2%
Sample handling (SH) 1,625 9.4% 134 0.8% 730 4.2% 2,489 14.4%
Sample receipt (SR) 630 3.6% 110 0.6% 83 0.5% 823 4.8%
Sample Testing (ST) 511 2.9% 216 1.2% 86 0.5% 813 4.7%
Miscellaneous (MS) 330 1.9% 52 0.3% 119 0.7% 501 2.9%
Total 12,845 74.1% 1,536 8.9% 2,963 17.1% 17,344 100%
Table 12. Transfusion errors of different levels of potential severity reported by different group of hospitals, TESS 2012-2013
Type of error (code) Small transfusion capacity hospitals Medium transfusion capacity hospitals Large transfusion capacity hospitals Total
Freq. % Freq. % Freq. % Freq. %
Low potential severity 294 77.2% 2,011 66.0% 10,540 75.7% 12,845 74.1%
Medium potential severity 34 8.9% 369 12.1% 1,133 8.1% 1,536 8.9%
High potential severity 53 13.9% 666 21.9% 2,244 16.1% 2,963 17.1%
Total 381 100% 3,046 100% 13,917 100% 17,344 100%

d) Transfusion-related errors that did not reach the patients

Approximately 93.4% (n=16,193) of the transfusion-related errors reported in 2012 and 2013 were detected before they reached the patients (Table 13). Planned detection procedures in place in hopitals participating in the TESS were credited with the detection of 97.7% (n=15,817) of these errors (Table 14a). The remaining 2.3% (n=376) were detected through unplanned procedures i.e. by chance.

Table 13: Errors that did not reach the patients by occurrence & detection locations (n=16,193), TESS 2012-2013

Discovery

Occurrence
Blood supplier Emergency Room Intensive care unit Lab. Service Medical/ Surgical Unit Obstetrics Operating Room Outpatient clinics Supplier/ Service provider Transfusion Service Total
Blood supplier 4 (0.6%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 10 (0.3%) 14 (0.1%)
Emergency Room 4 (0.6%) 93 (2.7%) 1 (0.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.3%) 8 (0.3%) 107 (0.7%)
Intensive care unit 6 (0.8%) 1 (0.0%) 274 (16.5%) 0 (0.0%) 3 (0.1%) 1 (0.1%) 4 (0.4%) 2 (0.1%) 2 (2.6%) 25 (0.9%) 318 (2.0%)
Laboratory service 2 (0.3%) 4 (0.1%) 3 (0.2%) 3 (3.5%) 4 (0.1%) 0 (0.0%) 0 (0.0%) 4 (0.2%) 0 (0.0%) 0 (0.0%) 20 (0.1%)
Medical/Surgical Unit 10 (1.4%) 5 (0.1%) 1 (0.1%) 0 (0.0%) 181 (5.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.3%) 24 (0.8%) 222 (1.4%)
Obstetrics 0 (0.0%) 0 (0.0%) 1 (0.1%) 0 (0.0%) 0 (0.0%) 9 (1.2%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (0.1%) 13 (0.1%)
Operating room 4 (0.6%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 2 (0.1%) 0 (0.0%) 167 (15.8%) 5 (0.3%) 2 (2.6%) 10 (0.3%) 191 (1.2%)
Outpatient clinics 2 (0.3%) 2 (0.1%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 110 (5.9%) 0 (0.0%) 44 (1.5%) 159 (1.0%)
Supplier/Service provider 3 (0.4%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 4 (0.1%) 0 (0.0%) 0 (0.0%) 1 (0.1%) 0 (0.0%) 1 (0.0%) 9 (0.1%)
Transfusion Service 681 (95.1%) 3,384 (97%) 1,377 83.1%) 82 (96.6%) 3,357 (94.5%) 762 (98.7%) 884 (83.8%) 1,728 (93.4%) 71 (92.2%) 2,814 (95.7%) 15,140 (93.5%)
Total 716 (100%) 3,490 (100%) 1,657 (100%) 85 (100%) 3,552 (100%) 772 (100%) 1,055 (100%) 1,850 (100%) 77 (100%) 2,939 (100%) 16,193 (100%)

Transfusion Services demonstrated highest efficiency for detecting not only from within the blood bank, but also from clinical areas. Transfusion Services detected 93.5% (n=15,140) of the transfusion-related errors that did not reach the patients; this included 95.7% (n=2,939) of their of their own errors (Table 13).

The overwhelming majority (97.7%; n=15,817) of transfusion-related errors that did not reach the patients was detected through planned detection procedures(Table 14a). of those that were discovered though uplanned procedures (n=376), the most commonly reported (Table 14b) were related to product request (10.9%; n=41), sample testing (16.8%; n=63) and unit transfusion (19.9%; n=75). Also, Transfusion Services accounted for 43.4% (n=163) of all these errors, followed by medical/surgical wards (n=67) and emergency rooms (n=45) which posted 17.8% and 12.0%, respectively (Table 14b).

Table 14a. Location of occurrence of transfusion-related errors that did not reach the patients & were detected through planned procedures (n=15,817), TESS 2012-2013
Type of error (code) Blood Supplier Emergency room Intensive care unit Laboratory service Medical/

Surgical ward

Obstetrics unit Operating room Outpatient clinics Supplier/ Service provider Transfusion Service Total
Distribution code (DC) 701 (4.4 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 701 (4.4 %)
Product check-in (PC) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 387 (2.4 %) 387 (2.4 %)
Unit storage (US) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 121 (0.8 %) 121 (0.8 %)
Inventory management (IM) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 124 (0.8 %) 124 (0.8 %)
Product request (PR) 0 (0.0 %) 137 (0.9 %) 148 (0.9 %) 0 (0.0 %) 320 (2.0 %) 131 (0.8 %) 79 (0.5 %) 188 (1.2 %) 2 (0.0 %) 0 (0.0 %) 1,005 (6.4%)
Request for pick-up (RP) 0 (0.0 %) 83 (0.5 %) 94 (0.6 %) 0 (0.0 %) 171 (1.1 %) 16 (0.1 %) 35 (0.2 %) 40 (0.3 %) 6 (0.0 %) 0 (0.0 %) 445 (2.8 %)
Product selection (PS) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 29 (0.2 %) 29 (0.2 %)
Unit manipulation (UM) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 223 (1.4 %) 223 (1.4 %)
Unit issue (UI) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 259 (1.6 %) 259 (1.6 %)
Unit transfusion (UT) 0 (0.0 %) 254 (1.6 %) 571 (3.6 %) 0 (0.0 %) 455 (2.9 %) 23 (0.1 %) 535 (3.4 %) 172 (1.1 %) 4 (0.0 %) 0 (0.0 %) 2,014 (12.7 %)
Sample collection (SC) 0 (0.0 %) 2,392 (15.1 % 542 (3.4 %) 0 (0.0 %) 1,909 (12.1 %) 372 (2.4 %) 241 (1.5 %) 768 (4.9 %) 3 (0.0 %) 0 (0.0 %) 6,227 (39.4 %)
Sample handling (SH) 0 (0.0 %) 560 (3.5 %) 277 (1.8 %) 0 (0.0 %) 612 (3.9 %) 209 (1.3 %) 122 (0.8 %) 67 (3.8 %) 6 (0.0 %) 0 (0.0 %) 2,393 (15.1 %)
Sample receipt (SR) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 20 (0.1 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 734 (4.6 %) 754 (4.8 %)
Sample Testing (ST) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 4 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 691 (4.4 %) 695 (4.4 %)
Miscellaneous (MS) 2 (0.0 %) 19 (0.1 %) 7 (0.0 %) 57 (0.4 %) 18 (0.1 %) 12 (0.1 %) 19 (0.1 %) 46 (0.3 %) 52 (0.3 %) 208 (1.3 %) 440 (2.8 %)
Total 703 (4.4%) 3,445 (21.8 %) 1,639 (10.4%) 81 (0.5 %) 3,485 (22.0%) 763 (4.8 %) 1,031 (6.5%) 1,821 (11.5 %) 73 (0.5%) 2,776 (17.6 %) 15,817 (100%)
Table 14b. Location of occurrence of transfusion-related errors that did not reach the patients & were detected through unplanned procedures (n=376), TESS 2012-2013
Type of error (code) Blood Supplier Emergency room Intensive care unit Laboratory service Medical/ Surgical ward Obstetrics unit Operating room Outpatient clinics Supplier/ Service provider Transfusion Service Total
Distribution code (DC) 13 (3.5 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 13 (3.5 %)
Product check-in (PC) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 11 (2.9 %) 11 (2.9 %)
Unit storage (US) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 7 (0.8 %) 7 (1.9 %)
Inventory management (IM) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 6 (1.6 %) 6 (1.6 %)
Product request (PR) 0 (0.0 %) 12 (3.2 %) 3 (0.8 %) 0 (0.0 %) 17 (4.5 %) 0 (0,0 %) 3 (0.8 %) 6 (1.6 %) 0 (0.0 %) 0 (0.0 %) 41 (10.9 %)
Request for pick-up (RP) 0 (0.0 %) 0 (0.0 %) 2 (0.5 %) 0 (0.0 %) 9 (2.4 %) 0 (0,0 %) 2 (0.5 %) 2 (0.5 %) 2 (0.5 %) 0 (0.0 %) 17 (4.5 %)
Product selection (PS) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 6 (1.6 %) 6 (1.6 %)
Unit manipulation (UM) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 9 (2.4 %) 9 (2.4 %)
Unit issue (UI) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 28 (7.4 %) 28 (7.4 %)
Unit transfusion (UT) 0 (0.0 %) 15 (4.0 %) 9 (2.4 %) 0 (0.0 %) 30 (8.0 %) 1 (0.3 %) 14 (3.7 %) 6 (1.6 %) 0 (0.0 %) 0 (0.0 %) 75 (19.9 %)
Sample collection (SC) 0 (0.0 %) 10 (2.7%) 3 (0.8 %) 0 (0.0 %) 6 (1.6 %) 4 (1.1 %) 2 (0.5 %) 4 (1.1 %) 0 (0.0 %) 0 (0.0 %) 29 (7.7 %)
Sample handling (SH) 0 (0.0 %) 3 (0.8 % 1 (0.3 %) 0 (0.0 %) 1 (0.3 %) 1 (0.3 %) 0 (0.0 %) 8 (2.1 %) 1 (0.3 %) 0 (0.0 %) 15 (4.0 %)
Sample receipt (SR) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 3 (0.8 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 21 (5.6 %) 24 (6.4 %)
Sample Testing (ST) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 63 (16.8 %) 63 (16.8 %)
Miscellaneous (MS) 0 (0.0 %) 5 (1.3 %) 0 (0.0 %) 1 (0.3 %) 4 (1.1 %) 3 (0.8 %) 3 (0.8 %) 3 (0.8 %) 1 (0.3 %) 12 (3.2 %) 32 (8.5 %)
Total 13 (3.5%) 45 (12.0 %) 18 (4.8%) 4 (1.1 %) 67 (17.8%) 9 (2.4 %) 24 (6.4%) 29 (7.7 %) 4 (1.1 %) 163 (17.6 %) 376 (100%)

Transfusion Services also showed high efficiency in detecting errors through unplanned procedures as they accounted for the detection of 79.8% (n=300) of all the errors that did not reach the patients including 95.1% (n=155) of theirs (Table 15).

Table 15: Transfusion-related errors deteced through unplanned procedures by occurrence & detection locations (n=376), TESS 2012-2013

Discovery

Occurrence
Blood supplier Emergency Room Intensive care unit Lab. Service Medical/ Surgical Unit Obstetrics Operating Room Outpatient clinics Supplier/ Service provider Transfusion Service Total
Blood supplier 3 (23.1 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 1 (0.6 %) 4 (1.1 %)
Emergency Room 0 (0.0 %) 7 (15.6 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 7 (1.9 %)
Intensive care unit 0 (0.0 %) 0 (0.0 %) 2 (11.1 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 2 (8.3 %) 1 (3.4 %) 1 (25.0 %) 2 (1.2 %) 8 (2.1 %)
Laboratory service 0 (0.0 %) 1 (2.2 %) 0 (0.0 %) 1 (25.0 %) 2 (3.0 %) 0 (0.0 %) 0 (0.0 %) 2 (6.9 %) 0 (0,0 %) 0 (0.0 %) 6 (1.6 %)
Medical/Surgical Unit 0 (0.0 %) 4 (8.9 %) 0 (0.0 %) 0 (0.0 %) 15 (22.4 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 2 (1.2 %) 21 (5.6 %)
Obstetrics 0 (0.0 %) 0 (0.0 %) 1 (5.6 %) 0 (0.0 %) 0 (0,0 %) 2 (22.2 %) 0 (0,0 %) 0 (0.0 %) 0 (0.0 %) 2 (1.2 %) 5 (1.3 %)
Operating room 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 1 (1.5 %) 0 (0.0 %) 8 (33.3 %) 2 (6.9 %) 1 (25.0 %) 2 (1.2 %) 14 (3.7 %)
Outpatient clinics 0 (0.0 %) 2 (4.4 %) 0 (0.0 %) 0 (0.0 %) 1 (1.5 %) 0 (0.0 %) 0 (0.0 %) 6 (20.7 %) 0 (0.0 %) 2 (1.2 %) 11 (2.9 %)
Supplier/Service provider 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %)
Transfusion Service 10 (76.9 %) 31 (68.9 %) 15 (83.3 %) 3 (75.0 %) 48 (71.6 %) 7 (77.8 %) 14 (58.3 %) 18 (62.1 %) 2 (50.0 %) 155 (95.1%) 300 (79.8 %)
Total 13 (100 %) 45 (100 %) 18 (100 %) 4 (100 %) 67 (100%) 9 (100 %) 24 (6.5 100 %) 29 (100 %) 4 (100 %) 163 (100 %) 376 (100 %)

e) Transfusion-related errors that reached the patients (i.e. detected post transfusion)

Of all the 17,344 transfusion-related errors reported in 2012 and 2013, only 6.6% (n=1,151) reached the patients (Tables 16 & 17). Of these, those related to product request (n=253), request for pick-up (n=388) and unit transfusions (n=113) were the most common as they accounted for about 22.0%, 33.7% and 9.8%, respectively (Tables 16 & 17).

Table 16. Rate of occurrence of transfusion-related errors that reached the patients (n=1,151), TESS 2012-2013
Type of error (code) 2012 2013 Overall
Freq. (%) RateFootnote 5 Risk of 1 errorFootnote 6 Freq. (%) Rate Risk of 1 error Freq. (%) Rate Risk of 1 error
Distribution code (DC) 16 (1.4%) 7 1 : 13,474 21 (1.8%) 11 1 : 8,994 37 (3.2%) 9 1 : 10,931
Product check-in (PC) 3 (0.3%) 1 1 : 71,861 2 (0.2%) 1 1 : 94,440 5 (0.4%) 1 1 : 80,893
Unit storage (US) 2 (0.2%) 1 1 : 107,792 0 (0.0%) 0 - 2 (0.2%) 0 1 : 202,232
Inventory management (IM) 7 (0.6%) 3 1 : 30,798 3 (0.3%) 2 1 : 62,960 10 (0.9%) 2 1 : 40,446
Product request (PR) 128 (11.1%) 56 1 : 1,782 125 (10.9%) 63 1 : 1,595 253 (22.0%) 59 1 : 1,690
Product selection (PS) 14 (1.2%) 6 1 : 16,973 13 (1.1%) 6 1 : 16,208 27 (2.3%) 6 1 : 16,605
Unit manipulation (UM) 11 (1.0%) 5 1 : 21,602 13 (1.1%) 6 1 : 16,208 24 (2.1%) 5 1 : 18,680
Request for pick-up (RP) 141 (12.3%) 63 1 : 1,599 247 (21.5%) 124 1 : 807 388 (33.7%) 91 1 : 1,095
Unit issue (UI) 23 (2.0%) 10 1 : 9,801 37 (3.2%) 19 1 : 5,386 60 (5.2%) 14 1 : 7,079
Unit transfusion (UT) 58 (5.0%) 26 1 : 3,887 55 (4.8%) 28 1 : 3,623 113 (9.8%) 27 1 : 3,759
Sample collection (SC) 15 (1.3%) 10 1 : 9,801 7 (0.6%) 5 1 : 19,491 22 (1.9%) 8 1 : 12,766
Sample handling (SH) 49 (4.3%) 34 1 : 2,947 32 (2.8%) 23 1 : 4,264 81 (7.0%) 29 1 : 3,467
Sample receipt (SR) 26 (2.3%) 18 1 : 5,554 19 (1.7%) 14 1 : 7,181 45 (3.9%) 16 1 : 6,241
Sample Testing (ST) 34 (3.0%) 11 1 : 8,764 21 (1.8%) 8 1 : 12,863 55 (4.8%) 10 1 : 10,329
Miscellaneous (MS) 17 (1.5%) - - 12 (1.0%) - - 29 (2.5%) - -
Total 544 (47.3%) - - 607 (52.7%) - - 1,151 (100%) - -
Table 17. Rate of occurrence of transfusion-related errors that reached the patients (n=1,151) by type of reporting hospitals, TESS 2012-2013.
Type of error (code) Small transfusion Capacity Medium transfusion Capacity Large transfusion

capacity

Overall
Freq. (%) RateFootnote 7 Risk of 1 errorFootnote 8 Freq. (%) Rate Risk of 1 error Freq. (%) Rate Risk of 1 error Freq. (%) Rate Risk of 1 error
Distribution code (DC) 3 (0.3%) 28 1 : 3,542 24 (2.1%) 19 1 : 5,258 10 (0.9%) 4 1 : 26,766 37 (3.2%) 9 1 : 10,931
Product check-in (PC) 1 (0.1%) 9 1 : 10,625 2 (0.2%) 2 1 : 63,091 2 (0.2%) 1 1 : 133,829 5 (0.4%) 1 1 : 80,893
Unit storage (US) 0 (0.0%) - 1 (0.1%) 1 1 : 126,181 1 (0.1%) 0 1 : 267,658 2 (0.2%) 0 1 : 202,232
Inventory management (IM) 2 (0.2%) 19 1 : 5,313 3 (0.3%) 2 1 : 42,060 5 (0.4%) 2 1 : 53,532 10 (0.9%) 2 1 : 40,446
Product request (PR) 6 (0.5%) 69 1 : 1,445 18 (1.6%) 14 1 : 7,119 229 19.9%) 79 1 : 1,269 253 (22.0%) 59 1 : 1,690
Product selection (PS) 0 (0.0%) 0 - 8 (0.7%) 6 1 : 17,111 19 (1.7%) 6 1 : 16,052 27 (2.3%) 6 1 : 16,605
Unit manipulation (UM) 0 (0.0%) 0 - 9 (0.8%) 7 1 : 15,210 15 (1.3%) 5 1 : 20,333 24 (2.1%)) 5 1 : 18,680
Request for pick-up (RP) 2 (0.2%) 29 1 : 3,484 21 (1.8%) 16 1 : 6,101 365 (31.7%) 126 1 : 794 388 (33.7%) 91 1 : 1,095
Unit issue (UI) 0 (0.0%) 0 - 25 (2.2%) 20 1 : 5,125 35 (3.0%) 12 1 : 8,275 60 (5.2%) 14 1 : 7,079
Unit transfusion (UT) 3 (0.3%) 43 1 : 2,323 65 (5.6%) 51 1 : 1,971 45 (3.9%) 16 1 : 6,436 113 ()9.8%) 27 1 : 3,759
Sample collection(SC) 0 (0.0%) 0 - 11 (1.0%) 15 1 : 6,512 11 (1.0%) 6 1 : 17,736 22 (1.9%) 8 1 : 12,766
Sample handling (SH) 3 (0.3%) 21 1 : 4,707 4 (0.3%) 6 1 : 17,908 74 (6.4%) 38 1 : 2,636 81 (7.0%) 29 1 : 3,467
Sample receipt (SR) 3 (0.3%) 21 1 : 4,707 11 (1.0%) 15 1 : 6,512 31 (2.7%) 16 1 : 6,293 45 (3.9%) 16 1 : 6,241
Sample Testing (ST) 1 (0.1%) 8 1 : 13,315 22 (1.9%) 15 1 : 6,462 32 (2.8%) 8 1 : 12,894 55 (4.8%) 10 1 : 10,329
Miscellaneous (MS) 1 (0.1%) - - 22 (1.9%) - - 6 (0.5%) - - 29 (2.5%) - -
Total 25 (2.2%) - - 246 (21.4%) - - 880 (76.5%) - - 1,151 (100%) - -

Cases that originated from large capacity hospitals (i.e. transfusing more than 10,000 units of red blood cells annually) were about 3.6 times that from hospitals transfusing between 2,000 and 10,000 units per year, and over 35 times that reported by hospitals transfusing less than 2,000 units per year (Table 17).

Not all the errors that reached the patients resulted in harm to the patient. In 73.8% (n=850) of the cases, transfusion procedure was delayed (Table 18) without impact to the patients and, in an additional 19.1% (n=220), though the errors were discovered after the product had been transfused, there was no negative impact to the the patient. Only 3.0% (n=34) of the errors that reached the patients resulted in adverse transfusion reactions (Table 19). The most common of these reactions was transfusion-associated circulatory overload (TACO) with 22 cases (64.7%) followed by febrile non-hemolytic and minor allergic reactions. Errors that led to TACO were related to product request (PR 04, PR 06, and PR 99) and not following guidelines for infusion time (UT 25) as detailed in Table 19; whereas those that resulted in febrile non-hemolytic and minor allergic reactions included inappropriate order of blood product (PR 06), and not following guidelines for infusion time (UT 25) or transfusion reaction protocol (UT 26). Other adverse reactions that resulted from transfusion-related errors included two cases of acute hemolytic & delayed serologic transfusion reactions (Table 19) respectively from incorrect selection of product/unit (PS 01) and sample testing error (ST 99), as well as a case of IVIG-related headache from not following transfusion reaction protocol (UT 26).

Table 18. Outcome of transfusion errors discovered during/after (n=1,151) transfusion, TESS 2012-2013.
Type of error (code) CQ 01

(Procedure delayed/cancelled)

CQ 02

(Transfusion delayed)

CQ 03

(Adverse reactions)

CQ 04

(Product transfused, but no adverse reaction)

CQ 05

(Incorrect dose admistered, but no adverse reaction)

CQ 06

(Loss traceability)

Total
Freq. (%) Freq. (%) Freq. (%) Freq. (%) Freq. (%) Freq. (%) Freq. (%)
Distribution code (DC) 0 (0.0%) 34 (3.0%) 0 (0.0%) 2 (0.2%) 0 (0.0%) 0 (0.0%) 36 (3.1%)
Product check-in (PC) 0 (0.0%) 5 (0.4%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 5 (0.4%)
Unit storage (US) 0 (0.0%) 1 (0.1%) 0 (0.0%) 1 (0.1%) 0 (0.0%) 0 (0.0%) 2 (0.2%)
Inventory management (IM) 0 (0.0%) 5 (0.4%) 0 (0.0%) 3 (0.3%) 0 (0.0%) 2 0.2% 10 (0.9%)
Product request (PR) 4 (0.3%) 186 (16.2%) 26 (2.3%) 37 (3.2%) 0 (0.0%) 0 (0.0%) 253 (22.0%)
Request for pick-up (RP) 0 (0.0%) 383 (33.3%) 0 (0.0%) 4 (0.3%) 1 (0.1%) 0 (0.0%) 388 (33.7%)
Product selection (PS) 0 (0.0%) 11 (1.0%) 1 (0.1%) 13 (1.1%) 2 (0.2%) 0 (0.0%) 27 (2.3%)
Unit manipulation (UM) 1 (0.1%) 16 (1.4%) 0 (0.0%) 5 (0.4%) 2 (0.2%) 0 (0.0%) 24 (2.1%)
Unit issue (UI) 0 (0.0%) 30 (2.6%) 0 (0.0%) 27 (2.3%) 3 (0.3%) 0 (0.0%) 60 (5.2%)
Unit transfusion (UT) 0 (0.0%) 21 (1.8%) 6 (0.5%) 64 (5.6%) 11 (1.0%) 11 (1.0%) 113 (9.8%)
Sample collection (SC) 1 (0.1%) 20 (1.7%) 0 (0.0%) 2 (0.2%) 0 (0.0%) 0 (0.0%) 23 (2.0%)
Sample handling (SH) 1 (0.1%) 64 (5.6%) 0 (0.0%) 16 (1.4%) 0 (0.0%) 0 (0.0%) 81 (7.0%)
Sample receipt (SR) 1 (0.1%) 19 (1.7%) 0 (0.0%) 24 (2.1%) 1 (0.1%) 0 (0.0%) 45 (3.9%)
Sample Testing (ST) 4 (0.3%) 30 (2.6%) 1 (0.1%) 20 (1.7%) 0 (0.0%) 0 (0.0%) 55 (4.8%)
Miscellaneous (MS) 2 (0.2%) 25 (2.2%) 0 (0.0%) 2 (0.2%) 0 (0.0%) 0 (0.0%) 29 (2.5%)
Total 14 (1.2%) 850 (73.8%) 34 (3.0%) 220 (19.1%) (20) (1.7%) 13 (1.1%) 1,151 (100%)
Table 19. Harm caused by transfusion errors detected (n=34), TESS 2012-2013
Type of error (code) Acute hemolytic transfusion reaction Delayed serologic transfusion reaction Febrile non-hemolytic reaction IVIG Headache Minor Allergic Reaction Transfusion-associated circulatory overload (TACO) Total
Hospitals of large transfusion capacity (i.e. transfusing more than 10,000 RBC per year)
Order not done or incorrect (PR 04) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (8.8%) 3 (8.8%)
Inappropriate order of blood product (PR 06) 0 (0.0%) 0 (0.0%) 4 (11.8%) 0 (0.0%) 2 (5.9%) 3 (8.8%) 9 (26.5%)
Product request error of unspecified nature (PR 99) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 14 (41.2%) 14 (41.2%)
Incorrect product/unit selected (PS 01) 1 (2.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.9%)
Guidelines for infusion time not followed (UT 25) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.9%) 1 (2.9%)
Subtotal 1 (2.9%) 0 (0.0%) 4 (11.8%) 0 (0.0%) 2 (5.9%) 21 (61.8%) 28 (82.4%)
Hospitals of medium transfusion capacity (i.e. transfusing 2,000-10,000 RBC per year)
Sample testing error of unspecified nature (ST 99) 0 (0.0%) 1 (2.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.9%)
Guidelines for infusion time not followed (UT 25) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.9%) 1 (2.9%) 2 (5.9%)
Transfusion reaction protocol not followed (UT 26) 0 (0.0%) 0 (0.0%) 1 (2.9%) 1 (2.9%) 0 (0.0%) 0 (0.0%) 2 (5.9%)
Subtotal 0 (0.0%) 1 (2.9%) 1 (2.9%) 1 (2.9%) 1 (2.9%) 1 (2.9%) 5 (14.7%)
Hospitals of small transfusion capacity (i.e. transfusing less than 2,000 RBC per year)
Transfusion reaction protocol not followed (UT 26) 0 (0.0%) 0 (0.0%) 1 (2.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.9%)
Subtotal 0 (0.0%) 0 (0.0%) 1 (2.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.9%)
Total 1 (2.9%) 1 (2.9%) 6 (17.6%) 1 (2.9%) 3 (8.8%) 22 (64.7%) 34 (100%)

In comparison, harmful errors from large (i.e. transfusing more than 10,000 RBC units per year) transfusion capacity hospitals (Tables 19 & 20) were related to product requests (n=26; 92.9%), product selection (n=1; 3.6%) and unit transfusion (n=1; 3.6%). These errors were determined to be associated with 21 cases of TACO, 4 cases of febrile non-hemolytic reactions (n=4), 2 cases of minor allergic reactions and one case of acute hemolytic reaction (Tables 19 & 20). The only harmful error detected in hospitals of small (i.e. transfusing less than 2,000 RBC units per year) transfusion capacity was non-adherence to transfusion reaction protocol (UT 26) which led to a case of febrile non-hemolytic reaction in an emergency room (Table 20).

Table 20. Location of occurrence of transfusion errors that caused HARM (n=34) in hospitals of various transfusion volumes, TESS 2012-2013.
Type of error (code) Emergency Room Intensive care unit Medical/ surgical ward Operating room Outpatient clinic Transfusion Service Total
Hospitals of large transfusion capacity (i.e. transfusing more than 10,000 RBC per year)
Order not done or incorrect (PR 04) 1 (2.9%) 2 (5.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (8.8%)
Inappropriate order of blood product (PR 06) 1 (2.9%) 3 (8.8%) 3 (8.8%) 1 (2.9%) 1 (2.9%) 0 (0.0%) 9 (26.5%)
Product request error of unspecified nature (PR 99) 2 (5.9%) 1 (2.9%) 11 (32.4%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 14 (41.2%)
Incorrect product/unit selected (PS 01) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.9%) 1 (2.9%)
Guidelines for infusion time not followed (UT 25) 0 (0.0%) 0 (0.0%) 1 (2.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.9%)
Subtotal 4 (11.8%) 6 (17.6%) 14 (41.2%) 1 (2.9%) 1 (2.9%) 1 (2.9%) 28 (82.4%)
Hospitals of medium transfusion capacity (i.e. transfusing 2,000-10,000 RBC per year)
Sample testing error of unspecified nature (ST 99) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.9%) 1 (2.9%)
Guidelines for infusion time not followed (UT 25) 1 (2.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.9%) 0 (0.0%) 2 (5.9%)
Transfusion reaction protocol not followed (UT 26) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (5.9%) 0 (0.0%) 2 (5.9%)
Subtotal 1 (2.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (8.8%) 1 (2.9%) 5 (14.7%)
Hospitals of small transfusion capacity (i.e. transfusing less than 2,000 RBC per year)
Transfusion reaction protocol not followed (UT 26) 1 (2.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.9%)
Subtotal 1 (2.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.9%)
Total 6 (17.6%) 6 (17.6%) 14 (41.2%) 1 (2.9%) 4 (11.8%) 2 (5.9%) 34 (100%)

About 91.2% (n=31) of the transfusion-related errors found to be associated with adverse transfusion reactions were of high potential severity (Table 21). Product request errors coded as PR 04, PR 06 and PR 99 were determined to be associated with 19 cases of TACO, 4 cases of febrile non-hemolytic transfusion reactions and 2 cases of minor allergic reactions. Additional cases of TACO and febrile non-hemolytic transfusion reactions (Table 21) were linked to not following either the guidelines for infusion time (UT 25) or the transfusion reaction protocol (UT 26). The other two errors deemed to be of high potential severity were related to product/unit selection (PS 01) and sample testing (ST 99) and were respectively determined to be linked to an acute hemolytic and a delayed serologic transfusion reactions. The remaining 8.2% (n=3) of the errors found to be associated with adverse transfusion reactions were of medium potential severity and were also related to incorrect /no ordering of blood or blood product (PR 04), not following the guidelines for infusion time (UT 25) and the transfusion reaction protocol (UT 26).

Table 21. High potential severity transfusion-related errors associated with harm to patients
Type of error (code) Acute hemolytic transfusion reaction Delayed serologic transfusion reaction Febrile non-hemolytic reaction Minor Allergic Reaction Transfusion-associated circulatory overload (TACO) Total
Order not done or incorrect (PR 04) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (6.5%) 2 (6.5%)
Inappropriate order of blood product (PR 06) 0 (0.0%) 0 (0.0%) 4 (11.8%) 2 (6.5%) 3 (8.8%) 9 (29.0%)
Product request error of unspecified nature (PR 99) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 14 (45.2%) 14 (45.2%)
Sampling testing error of unspecified nature (ST 99) 0 (0.0%) 1 (3.2%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (3.2%)
Incorrect product/unit selected (PS 01) 1 (3.2%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (3.2%)
Guidelines for infusion time not followed (UT 25) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (6.5%) 2 (6.5%)
Transfusion reaction protocol not followed (UT 26) 0 (0.0%) 0 (0.0%) 2 (6.5%) 0 (0.0%) 0 (0.0%) 2 (6.5%)
Total 1 (3.2%) 1 (3.2%) 6 (19.4%) 2 (6.5%) 21 (67.7%) 31 (100%)

Conclusion and future work

Overall, sample collection (SC) and sample handling (SH) errors remain the most frequent transfusion-related errors. Transfusion Services, as well as Medical/Surgical Wards and Emergency Rooms continue to be the locations where most of the transfusion-related errors occur. However, unlike Medical/Surgical Wards and Emergency Rooms that have been able to detect only less than 10% of errors that occurred in their units, Transfusion Services' error detection processes captured the vast majority (over 94%) of these errors.

Although the total number of errors recorded remains substantially high (n=17,344), the proportion that reaches the patients undetected represents just 6.6% (n=1,151). Of the errors that reach the patients, only about 3% actually resulted in an adverse reaction. Nevertheless, continued monitoring and improvements of the transfusion safety processes are recommended as the potential for harm resulting from transfusion errors can be considerable not only for the patients, but for the hospitals as well. Clinical settings demonstrated inefficacy in capturing their own errors; therefore, it is recommended to audit/review and potentially update the transfusion error detection procedures currently in place. Particular attention should be given to procedures targeting errors related to product requests, requests for pick-up and unit transfusion since these errors collectively represented the bulk of the errors that reached the patients.

The TESS working group has shown that it is possible to improve error tracking within the clinical and transfusion areas even when there are existing SOPs, etc. Future work will target interventions to increase timely error tracking outside the Transfusion Services, particularly those related to sample collection and transfusion documentation (such as product requests and requests for pick-up). The Agency through the TESS working group will also assess the feasibility of partnering with the Canadian Patient Safety Institute (CPSI) in order to address the issues related to patient identification.

References

  1. Public Health Agency of Canada. Transfusion Transmitted Injuries Surveillance System (TTISS): 2006-2012 Report. Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, 2014.

Appendix 1: Transfusion-related errors discovered through quality assurrance review and audits of the inventory and transfusion documentation more than 2 days after the event had occurred

Approximately 63.0% (n=3,777) of transfusion-related errors detected through quality assurance review and inventory audit and review of transfusion documentation more than two days after the events had occurred (Table 22) were discovered more than 30 days (41.3%; n=2,476) or between 15 to 30 days (21.7%; n=1,301) later. Errors related to sample collection, product storage, unit transfusion and unit issue account for 27.3% (n=1,636), 24.9% (n=1,494), 20.4% (n=1,221) and 14.3% (n=859), respectively (Table 22). The breakdown of the specific errors under these categories is summarized in Table 23 and the description of specific event codes provided in Appendix 2.

Table 22: Transfusion-related errors detected through quality assurance review, inventory audit and review of transfusion documentation more than two days after the events had occurred
  Discovered 2-7 days after occurrence Discovered 8-14 days after occurrence Discovered 15-30 days after occurrence Discovered more than 30 days after occurrence Total
Freq % Freq % Freq % Freq % Freq %
Distribution code (DC) 7 0.1% 2 0.0% 0 0.0% 3 0.1% 12 0.2%
Product check-in (PC) 38 0.6% 13 0.2% 30 0.5% 22 0.4% 103 1.7%
Unit storage (US) 189 3.2% 294 4.9% 556 9.3% 455 7.6% 1,494 24.9%
Inventory management (IM) 19 0.3% 12 0.2% 14 0.2% 15 0.3% 60 1.0%
Product request (PR) 16 0.3% 2 0.0% 0 0.0% 2 0.0% 20 0.3%
Request for pick-up (RP) 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0%
Product selection (PS) 6 0.1% 0 0.0% 1 0.0% 0 0.0% 7 0.1%
Unit manipulation (UM) 14 0.2% 6 0.1% 26 0.4% 48 0.8% 94 1.6%
Unit issue (UI) 147 2.5% 175 2.9% 347 5.8% 190 3.2% 859 14.3%
Unit transfusion (UT) 794 13.2% 230 3.8% 144 2.4% 53 0.9% 1,221 20.4%
Sample collection (SC) 1 0.0% 9 0.2% 31 0.5% 1,595 26.6% 1,636 27.3%
Sample handling (SH) 4 0.1% 0 0.0% 0 0.0% 0 0.0% 4 0.1%
Sample receipt (SR) 38 0.6% 7 0.1% 1 0.0% 4 0.1% 50 0.8%
Sample Testing (ST) 78 1.3% 70 1.2% 120 2.0% 70 1.2% 338 5.6%
Miscellaneous (MS) 30 0.5% 21 0.4% 31 0.5% 19 0.3% 101 1.7%
Total 1,381 23.0% 841 14.0% 1,301 21.7% 2,476 41.3% 5,999 100%
Table 23: Transfusion-related errors discovered through quality assurrance review, inventory audit & review of transfusion documentation more than 2 days after they had occurred
Specific error code

(Dscription provided in Appendix 2)

2012 2013 Total
Frequency Percentage Frequency Percentage Frequency Percentage
DC 02 1 0.0% 1 0.0% 2 0.1%
DC 04 1 0.0% 2 0.1% 3 0.1%
DC 05 1 0.0% 0 0.0% 1 0.0%
DC 08 2 0.0% 2 0.1% 4 0.1%
DC 99 1 0.0% 1 0.0% 2 0.1%
All DC errors 6 0.1% 6 0.2% 12 0.4%
PC 01 28 0.5% 67 2.2% 95 3.1%
PC 05 4 0.1% 1 0.0% 5 0.2%
PC 06 0 0.0% 1 0.0% 1 0.0%
PC 99 0 0.0% 2 0.1% 2 0.1%
All PC errors 32 0.5% 71 2.4% 103 3.4%
IM 01 4 0.1% 2 0.1% 6 0.2%
IM 02 19 0.3% 29 1.0% 48 1.6%
IM 03 0 0.0% 1 0.0% 1 0.0%
IM 04 1 0.0% 2 0.1% 3 0.1%
IM 99 2 0.0% 0 0.0% 2 0.1%
All IM errors 26 0.4% 34 1.1% 60 2.0%
US 01 1 0.0% 0 0.0% 1 0.0%
US 02 1 0.0% 0 0.0% 1 0.0%
US 03 654 10.9% 796 26.4% 1,450 48.1%
US 04 1 0.0% 3 0.1% 4 0.1%
US 99 1 0.0% 37 1.2% 38 1.3%
All US errors 658 11.0% 836 27.7% 1,494 49.5%
PR 04 1 0.0% 3 0.1% 4 0.1%
PR 06 3 0.1% 1 0.0% 4 0.1%
PR 07 0 0.0% 1 0.0% 1 0.0%
PR 99 6 0.1% 5 0.2% 11 0.4%
All PR errors 10 0.2% 10 0.3% 20 0.7%
PS 01 1 0.0% 4 0.1% 5 0.2%
PS 09 1 0.0% 0 0.0% 1 0.0%
PS 99 0 0.0% 1 0.0% 1 0.0%
All PS errors 2 0.0% 5 0.2% 7 0.2%
UM 01 32 0.5% 23 0.8% 55 1.8%
UM 05 1 0.0% 2 0.1% 3 0.1%
UM 09 0 0.0% 3 0.1% 3 0.1%
UM 99 33 0.6% 0 0.0% 33 1.1%
All UM errors 66 1.1% 28 0.9% 94 3.1%
UI 01 67 1.1% 39 1.3% 106 3.5%
UI 04 1 0.0% 0 0.0% 1 0.0%
UI 06 0 0.0% 1 0.0% 1 0.0%
UI 09 2 0.0% 5 0.2% 7 0.2%
UI 19 0 0.0% 2 0.1% 2 0.1%
UI 21 348 5.8% 387 12.8% 735 24.4%
UI 99 5 0.1% 2 0.1% 7 0.2%
All UI errors 423 7.1% 436 14.5% 859 28.5%
UT 04 3 0.1% 4 0.1% 7 0.2%
UT 23 533 8.9% 313 10.5% 846 28.4%
UT 24 90 1.5% 37 1.2% 127 4.3%
UT 25 53 0.9% 73 2.4% 126 4.2%
UT 26 1 0.0% 3 0.1% 4 0.1%
UT 27 29 0.5% 60 2.0% 89 3.0%
UT 28 1 0.0% 4 0.1% 5 0.2%
UT 29 1 0.0% 1 0.0% 2 0.1%
UT 99 10 0.2% 5 0.2% 15 0.5%
All UT errors 721 12.0% 500 16.8% 1,221 40.9%
SC 06 0 0.0% 1 0.0% 1 0.0%
SC 08 5 0.1% 1,629 54.6% 1,634 54.8%
SC 99 1 0.0% 0 0.0% 1 0.0%
All SC errors 6 0.1% 1,630 54.7% 1,636 54.9%
SH 03 1 0.0% 0 0.0% 1 0.0%
SH 07 1 0.0% 0 0.0% 1 0.0%
SH 12 0 0.0% 1 0.0% 1 0.0%
SH 99 0 0.0% 1 0.0% 1 0.0%
All SH errors 2 0.0% 2 0.1% 4 0.1%
SR 02 1 0.0% 4 0.1% 5 0.1%
SR 03 18 0.3% 0 0.0% 18 0.3%
SR 04 5 0.1% 20 0.3% 25 0.4%
SR 99 2 0.0% 0 0.0% 2 0.0%
All SR errors 26 0.4% 24 0.4% 50 0.8%
ST 04 100 1.7% 108 1.8% 208 3.5%
ST 06 27 0.5% 60 1.0% 87 1.5%
ST 09 0 0.0% 1 0.0% 1 0.0%
ST 12 12 0.2% 1 0.0% 13 0.2%
ST 13 1 0.0% 0 0.0% 1 0.0%
ST 14 2 0.0% 3 0.1% 5 0.1%
ST 15 2 0.0% 0 0.0% 2 0.0%
ST 16 1 0.0% 0 0.0% 1 0.0%
ST 19 5 0.1% 2 0.0% 7 0.1%
ST 21 0 0.0% 1 0.0% 1 0.0%
ST 22 0 0.0% 1 0.0% 1 0.0%
ST 99 3 0.1% 8 0.1% 11 0.2%
All ST errors 153 2.6% 185 3.1% 338 5.6%
MS 03 0 0.0% 4 0.1% 4 0.1%
MS 04 5 0.1% 5 0.1% 10 0.2%
MS 05 3 0.1% 60 1.0% 63 1.1%
MS 06 4 0.1% 7 0.1% 11 0.2%
MS 99 9 0.2% 4 0.1% 13 0.2%
All MS errors 21 0.4% 80 1.3% 101 1.7%
Total 1,392 23.2% 1,625 53.9% 5,999 100%

Specific transfusion-related errors most frequently discovered through quality assurance review and audits of inventories and transfusion documentations more than two days after occurrence included (Table 23) unnecessary sample collection (SC 08) which accounted for 54.8% (n=1,634), followed by inappropriate monitoring of storage devices (US 03), incomplete documentation (UT 23) and non-verification of receipts (UI 21) representing respectively 48.1% (n=1,450), 28.4% (n=846) and 24.4% (n=735). The overall predominant error types discovered through the above-mentioned procedures differed from one province to another (Table 24), but was consistent from one year to another with the exception of province "D" which posted a very high proportion of sample collection (SC) errors in 2013. Unit transfusion (UT) errors were the most commonly reported from province "B", compared to unit storage (US), unit issue (UI) and sample testing (ST) errors which accounted for the majority (89.4%) of province "C" reports (Table 24).

Table 24: Transfusion-related errors discovered through quality assurrance review, audit of the inventory & transfusion documentation more than 2 Days after event occurrence
Error code Province

A

Province

B

Province

C

Province

D

Total
2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
DC 4 (0.2%) 4 (0.1%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 1 (0.0%) 1 (0.0%) 1 (0.0%) 6 (0.3%) 6 (0.2%)
PC 6 (0.3%) 9 (0.2%) 2 (0.1%) 3 (0.1%) 21 (1.0%) 54 (1.4%) 3 (0.1%) 5 (0.2%) 32 (1.5%) 71 (1.8%)
US 2 (0.1%) 0 (0.0%) 15 (0.7%) 15 (0.4%) 640 (29.7%) 820 (21.3%) 1 (0.0%) 1 (0.0%) 658 (30.6%) 836 (21.7%)
IM 2 (0.1%) 3 (0.1%) 4 (0.2%) 0 (0.0%) 2 (0.1%) 4 (0.1%) 18 (0.8%) 27 (0.7%) 26 (1.2%) 34 (0.9%)
PR 7 (0.3%) 6 (0.2%) 3 (0.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 4 (0.2%) 10 (0.5%) 10 (0.3%)
PS 0 (0.0%) 1 (0.0%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.0%) 4 (0.2%) 2 (0.1%) 5 (0.1%)
UM 0 (0.0%) 1 (0.0%) 1 (0.0%) 0 (0.0%) 61 (2.8%) 22 (0.6%) 4 (0.2%) 5 (0.2%) 66 (3.1%) 28 (0.7%)
UI 4 (0.2%) 5 (0.1%) 5 (0.2%) 0 (0.0%) 409 (19.0%) 422 (11.0%) 5 (0.2%) 9 (0.2%) 423 (19.7%) 436 (11.3%)
UT 0 (0.0%) 1 (0.0%) 683 (31.7%) 438 (11.4%) 18 (0.8%) 42 (1.1%) 20 (0.9%) 19 (0.5%) 721 (33.5%) 500 (13.0%)
SC 1 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 5 (0.2%) 1,630 (42.3%) 6 (0.3%) 1,630 (42.2%)
SH 0 (0.0%) 1 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (0.1%) 1 (0.0%) 2 (0.1%) 2 (0.1%)
SR 1 (0.0%) 0 (0.0%) 1 (0.0%) 1 (0.0%) 18 (0.8%) 16 (0.4%) 6 (0.3%) 7 (0.2%) 26 (1.2%) 24 (0.6%)
ST 10 (0.5%) 8 (0.2%) 8 (0.4%) 6 (0.2%) 122 (5.7%) 158 (4.1%) 13 (0.6%) 13 (0.3%) 153 (7.1%) 185 (4.8%)
MS 2 (0.1%) 0 (0.0%) 5 (0.2%) 7 (0.2%) 6 (0.3%) 40 (1.0%) 8 (0.4%) 33 (0.9%) 21(1.0%) 80 (2.1%)
Total 39 (1.8%) 39 (1.8%) 728 (33.8%) 470 (12.2%) 1,298 (60.3%) 1,579 (41.0%) 87 (4.0%) 1,759 (45.6%) 2,152 (100%) 3,847 (100%)

Appendix 2: Specific event codes & corresponding descriptions

Event code
Description of event

Errors related to Distributors (DC)

DC 00
Not specified
DC 01
Collection
DC 02
Processing/testing
DC 03
Labelling
DC 04
Packaging
DC 05
Transport
DC 06
Look-back traceback
DC 07
Recall Process
DC 08
Order incompletely / incorrectly filled
DC 99
Other

Errors related to Product Check-in (PC)

PC 00
Not specified
PC 01
Data entry incomplete/not performed/incorrect
PC 05
Inappropriate return to inventory
PC 06
Unit confirmation not done / incorrect
PC 07
Administrative check not done / incorrect
PC 99
Other

Errors related to Inventory Management (IM)

IM 00
Not specified
IM 01
Inventory audit not done / incorrect
IM 02
Product status not / incorrectly updated in computer-internal only (available / discard)
IM 03
Supplier recall / look back / trace back not addressed appropriately
IM 04
Product ordered incorrectly / not submitted to supplier
IM 99
Other

Errors related to Unit Storage (US)

US 00
Not specified
US 01
Incorrect storage of product in transfusion service
US 02
Expired product in stock
US 03
Inappropriate monitoring of storage device
US 04
Unit stored on incorrect shelf (Group / Autologous / Reserved)
US 99
Other

Errors related to Product Request (PR)

PR 00
Not specified
PR 01
Order for wrong patient
PR 02
Order incorrectly entered (online order entry)
PR 03
Special needs not indicated (e.g. Auto, CMV negative)
PR 04
Order not done / incorrect / incomplete
PR 06
Inappropriate order of a blood product
PR 07
Wrong product ordered (type)
PR 99
Other

Errors related to Sample Collection (SC)

SC 00
Not specified
SC 01
Sample labelled with wrong patient identification
SC 02
Not Labelled
SC 03
Wrong patient collected (not from intended patient)
SC 04
Collected in wrong tube type
SC 05
Sample NSQ (Non-Sufficient Quantity)
SC 06
Sample hemolysed
SC 07
Label incomplete /illegible for key patient identifiers (name, identification, birthdate)
SC 08
Sample collected unnecessarily
SC 09
Requisition arrives without samples
SC 10
Armband incorrect / not available
SC 12
Label incomplete / illegible for non-key patient identifiers
SC 99
Other

Errors related to Sample Handling (SH)

SH 00
Not specified
SH 01
Sample arrives without requisition
SH 02
Paperwork and sample ID do not match
SH 03
Patient ID incomplete/illegible on requisition
SH 04
No patient ID on requisition
SH 05
No phlebotomist / witness identification
SH 06
Sample arrives with incorrect type of requisition
SH 07
Patient information (other than ID) missing / incorrect on requisition
SH 10
Sample transport issues
SH 11
Incorrect test ordered / requested
SH 12
Test not ordered / requested
SH 99
Other

Errors related to Sample Receipt (SR)

SR 00
Not specified
SR 01
Sample accepted in error
SR 02
Historical review incorrect / not done
SR 03
Demographic review / entry incorrect / not done
SR 04
Sample incorrectly accessioned (test / product)
SR 99
Other

Errors related to Sample Testing (ST)

ST 00
Not Specified
ST 02
Appropriate sample check(s) not done / incorrect
ST 03
Computer warning overridden
ST 04
Data entry incomplete / not done
ST 05
Sample labelled with incorrect accession label
ST 06
Data entry incorrect
ST 09
Sample / test tubes mixed up / mislabelled
ST 12
Testing not done (ordered / confirmatory)
ST 13
Incorrect testing method chosen
ST 14
Testing performed incorrectly (did not follow SOP)
ST 15
Test result misinterpreted
ST 16
Inappropriate reagents used for testing
ST 19
Additional testing not performed
ST 20
Final check not done / incorrect
ST 21
Administrative check not done / incorrect (after the fact, record review, audit)
ST 22
Sample storage incorrect / inappropriate
ST 98
Quality control related (only to be used as 2nd event code)
ST 99
Other

Errors related to Request for Pick-up (RP)

RP 00
Not specified
RP 01
Request for pick-up on wrong patient
RP 02
Incorrect type / dose of product requested for pick-up
RP 03
Product requested prior to obtaining consent
RP 04
Product requested for pick-up, patient not ready / unavailable
RP 05
Product requested for pick-up IV not ready
RP 06
Request for pick-up incomplete (no Pt. Id, MRN / or product indicated)
RP 10
Product transport issues (internal)
RP 99
Other

Errors related to Product Selection (PS)

PS 00
Not specified
PS 01
Incorrect type / product / unit / dose selected
PS 07
Special needs not checked
PS 09
Special needs misinterpreted
PS 99
Other

Errors related to Unit Manipulation (UM)

UM 00
Not specified
UM 01
Data entry incomplete / incorrect
UM 04
Final check not done / incorrect
UM 05
Labelling incorrect
UM 09
Special processing not done / incorrectly done
UM 10
Administrative check not done / incorrect
UM 99
Other

Errors related to Unit Issue (UI)

UI 00
Not specified
UI 01
Data entry incomplete / incorrect
UI 04
Product issued to wrong patient
UI 06
LIS warning overridden (in error or outside SOP)
UI 09
Not checking/incorrect checking of unit and/or patient information)
UI 11
Product delivered to the incorrect location by the Transfusion Service (physical delivery)
UI 19
Wrong type / dose of product issued to right patient
UI 21
Receipt verification not done (pneumatic tube issue)
UI 22
Issue approval not obtained / documented
UI 99
Other

Errors related to Unit Transfusion (UT)

UT 00
Not specified
UT 01
Administered product to wrong patient
UT 02
Administered wrong type / dose of product to patient
UT 04
Incorrect storage of product on floor
UT 05
Bedside check not done / incorrect (unit/patient info)
UT 06
Administered product with incompatible IV fluid
UT 08
Wrong unit / product chosen from satellite refrigerator
UT 11
Appropriate monitoring of patient not done
UT 12
Floor/clinic did not check for existing units in their area
UT 13
Labelling incorrect
UT 22
Order / consent check not done / incorrect
UT 23
Documentation not complete / incorrect
UT 24
Documentation not returned
UT 25
Guidelines for infusion time not followed
UT 26
Transfusion reaction protocol not followed
UT 27
Monitoring of satellite fridge not done / incorrect
UT 28
Inappropriate preparation of product
UT 29
Product storage tracking incorrect / not done
UT 99
Other

Miscellaneous errors (MS)

MS 00
Not specified
MS 03
Patient registration incomplete/incorrect
MS 04
Equipment / computer failure
MS 05
Equipment QC not done/documented
MS 06
Reagent/material event
MS 07
Patient incurred event
MS 99
Other

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