Transfusion error surveillance system (TESS), 2017-2019

Transfusion error surveillance system (TESS) 2017-2019

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TESS project

To improve transfusion processes and patient safety, TESS captures non-nominal data regarding errors that occurred at any point in the transfusion chainFootnote 1

This project was initiated in 2005. The Transfusion Error Surveillance System (TESS):2012-2016 report contains a detailed methodology of TESS

Four jurisdictions participating in TESS monitor 16% of national blood transfusion activities in Canada

Surveillance data summary

30,157 errorsFootnote 2 (e.g. blood sample labelled with incorrect patient identification) were reported during 2017-2019

0.1% of all reported errors resulted in harmFootnote 3 to the patient

Overall counts of reported errors for 2017-2019Footnote 4
Overall counts of reported errors for 2017-2019
Text Description - Overall counts of reported errors for 2017-2019

All Errors: 30,157 (100%)

  • Near Miss: 29,095 (96.5%)
    • Planned Discovery: 28,824 (95.6%)
    • Unplanned Discovery: 271 (0.9%)
  • Actual Event: 1,062 (3.5%)
    • Harm: 23 (0.1%)
    • No Harm: 1,039 (3.4%)
Location of error occurrence
Location of error occurrence
Text Description - Location of error occurrence
Location Number of errors (n) Percentage (%)
Emergency 4,384 14
ICU 2,610 9
Medical/surgical ward 5,684 19
Obstetrics 933 3
Operating room 2,604 9
Outpatient clinics and procedures 4,056 13
Others 480 2
Transfusion laboratory 9,406 31
Harm caused by errorsFootnote 5,Footnote 6
Harm caused by errors
Text Description - Harm caused by errors
Type of Harm Number of Harm (n) Percentage (%)
TACOFootnote 5 15 65.2
OthersFootnote 6 8 34.8

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 improves transfusion safety

Learn more about TESS

More information on the Blood Safety Contribution Program web page

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