PMID: 29769867Nov 20, 2014Paper

A summary of the Transfusion Error Surveillance System: 2008 - 2011

Canada Communicable Disease Report = Relevé Des Maladies Transmissibles Au Canada
Aboubaker MounchiliC Hyson

Abstract

Although Canada has one of the safest blood systems in the world, transfusion errors can occur at any time from the moment of collection through to the transfusion of blood and blood products. The Transfusion Error Surveillance System (TESS) was initiated by the Public Health Agency of Canada (the Agency) to monitor transfusion-related errors occurring at any point in the transfusion chain. To offer an analysis of the TESS data reported from 2008 to 2011. Between 2008 and 2011, 12 to 15 hospitals from four provinces participated in the TESS. Reports on all transfusion-related errors were sent electronically on a quarterly basis to the Agency where they were consolidated, cleaned, validated and analyzed. Different types of transfusion errors were categorized by time of discovery (pre- or post-transfusion) and their potential impact on the patient's health. The occurrence rates of different types of errors were calculated using corresponding denominator data. Results were grouped by the transfusion capacity of reporting hospitals. Between 2008 and 2011, a total of 34,088 transfusion-related errors were reported. Of these, 33,622 (98.6%) were detected prior to transfusion. The most commonly reported were errors related to the coll...Continue Reading

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