Common Causes of Blood Transfusion Events in a University Hospital: Analysis of Incident Reports

Completed

• Conditions: Blood Transfusion Events

• Registration Number: NCT01812499
• Lead Sponsor: Universitaire Ziekenhuizen KU Leuven

Brief Summary

Inhospital the blood transfusion process consists of many phases: ordering the blood product, analysis of the blood sample, delivery, transport and storage of the blood product and administration. In each of these phases (near) accidents may occur. A severe transfusion incident refers to the transfusion of a wrong blood product, whereas a near miss is detected before transfusion.

In 2010 the University Hospitals Leuven introduced a new electronic patient incident report system for transfusion events.

In this study the investigators will analyze the reported blood transfusion events to detect the most common causes of blood transfusion events and the weakest link in the blood transfusion chain.

Detailed Description

A retrospective survey will be conducted of all transfusion events reported in the University Hospitals Leuven between January 2011 and July 2012. Both severe accidents and near misses will be included.

Data will be drawn from the incident report system. Data concerning the number of transfused blood products will be required from the Medical Administration Service.

Events will be classified according to the severity and the cause of the event. The different settings where the events took place will be compared using a chi-square test (p\<0,05).

Study Timeline

• Study Start: 2013-01
• Status Verified: 2013-02
• Primary Completion: 2013-02
• Study First Submitted: 2013-02-12
• Study First Submitted QC: 2013-03-13
• Last Update Submitted: 2013-03-13
• Study First Posted: 2013-03-18
• Last Update Posted: 2013-03-18

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 131

Inclusion Criteria

• all transfusion events reported in the University Hospitals Leuven between January 2011 and July 2012
• Both severe accidents and near misses were included

Exclusion Criteria

• Transfusion reactions

Study & Design

• Study Type: OBSERVATIONAL
• Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
Severity of inhospital blood transfusion events	up to 1,5 years	included events will be classified into near misses or severe incidents

Secondary Outcome Measures

Name	Time	Method
Causes of inhospital blood transfusion events	up to 1,5 years	Events are classified into human error, technical problems, deficiency of the blood product and others.; Events will also be classified considering the phase in the blood transfusion process.; Causes will be studied hospital wide and per setting were the event took place.

Trial Locations

Locations (1)

University Hospitals Leuven; 🇧🇪 Leuven, Belgium