Transfusion Error Surveillance System (TESS), 2022

TESS Project

The Transfusion Error Surveillance System (TESS) collects non-nominal data on errors that occur during the transfusion process for improving transfusion practices and patient safety. The surveillance system was initiated in 2005. TESS now monitors four provinces and territories and 16% of blood transfusion activities in Canada. Detailed methods of TESS can be found in the Transfusion error surveillance system (TESS) : 2012-2016 report.

Surveillance data summary

• 9,746^{Footnote 1}Errors^{Footnote 2} (e.g. blood sample labelled with incorrect patient identification) were reported in the year of 2022.
• 0.03% of all reported errors (e.g. 3 / 9, 746) resulted in harm^{Footnote 3} to the patient.

Overall counts of reported errors for 2022^{Footnote 4}

• All Errors^{Footnote 2} (9,746; 100%)
  • Near Miss (8,959; 91.9%)
    • Planned Discovery (8,879; 99.1%)
    • Unplanned Discovery (80; 0.9%)
  • Actual Event (787; 8.1%)
    • Harm (3; 0.4%)
    • No Harm (784; 99.6%)

Location of error occurrence

• Transfusion laboratory 19%
• Outpatient clinics /procedures 15%
• Operating room 12%
• Obstetrics 2%
• Medical/ surgical ward 20%
• ICU 12%
• Emergency 17%
• Others 3%

Harm caused by errors, TESS 2022

• FNHR^{Footnote 5} 1; 33.3%
• Other^{Footnote 6} 1; 33.3%
• TACO^{Footnote 7} 1; 33.3%

Implication

Reporting and investigating errors in both transfusion services and clinical settings help identify and control risks before resulting in harm to the patient, thus providing valuable opportunities to improve transfusion safety.

Learn more about TESS

Visit Canada.ca and search "Transfusion Error Surveillance System" and Follow us on Twitter @GovCanHealth