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Context:
The recognition of the symptoms of a transfusion reaction is a vital safety patient issue. One of the most useful indicators of whether the patient care staff is adequately recognizing and communicating complications of transfusions to the blood bank is the percent of reactions reported as a function of the number of blood products infused.
Objective:
The objective of the study was to establish a minimum threshold for transfusion reaction reporting by the clinical staff. Careful searching of available literature did not yield a “national” standard to be used as a benchmark. Our system wide Quality Improvement committee suggested that the data of our six transfusion services be tracked and reviewed to determine an internal threshold.
Methods:
The transfusion services at each of our facilities routinely reports the number of blood products infused and the number of transfusion reactions reported. This data was graphed over a period of 33 months. A significant educational effort was being made during this time to increase the clinical staff members awareness of the signs and symptoms of an adverse reaction to a blood product infusion including the publication of major transfusion reaction categories and symptoms on the back of the blood product infusion record.
Results:
The percent of transfusion reactions reported over the study period showed trend upward. Reaction reporting rates showed a nadir of 0.12% and a maximum reporting rate of 0.5%, which was due in large part to a single patient reacting during the infusion of a large quantity of products. The reporting rate has consistently been 0.19% or above for the last 9 quarters.
Conclusions:
Our threshold for action for the reporting of transfusion reactions will be set at 0.19%. A reaction rate of less than 0.19% will result in the development and execution of a corrective action plan.
See more of Poster Session
See more of The 2005 Institute for Quality in Laboratory Medicine Conference