某醫學中心輸血異常事件通報

Transfusion Incidents Reporting in a Medical Center

「台灣病人安全通報系統」自2004年規畫推行，其中「輸血事件」通報率偏低（0.5-1.8%）。本篇以高雄榮民總醫院對輸血作業有關事件的院內通報情形，分為兩期來分析比較。第一期為1996年10月至2003年12月，第二期為2004年1月至2007年3月。我們根據ISO15189醫學實驗室認證之要求，重新設計通報處理單。在本院原始「異常事件通報處理單」中增列了「檢驗前程序」、「檢驗程序」、及「檢驗後程序」等9大項43小項的「事件描述選項」。10年間共有73件通報記錄，第一期38件，屬院內自行通報，第二期35件則為全國性通報後之記錄。第一期的事件發生的地點皆為血庫，發現人員也皆為血庫醫檢人員，事件分類皆屬於「檢驗前程序」出現異常，且92.1%為檢體錯誤。第二期的輸血異常事件發生的地點主要是病房及門急診（57.1%），其次為血庫。主要發現者為護理人員（51.4%），其次為血庫醫檢人員，事件分類則以「檢驗後程序」發生次數最多，佔62.9%，並以血袋內有凝塊或滲血等血品不良事件為主，皆為護理人員所通報。其次為「檢驗前程序」，佔28.6%。發生兩次溶血性輸血反應，分別產生於「檢驗程序」及「檢驗後程序」，皆立刻實施「根本原因分析」。2004年後的輸血異常事件以影響病人為最多（85.7%），其近端原因與根本原因皆以系統因素為主，分佔57.1%與76.9%，大部份屬於一年內會發生的事件（78.9%）及中度或低度危險事件（84.2%），半數以上屬跡近錯失（52.6%），並對機構無傷害或輕度傷害（89.5%）。「台灣病人安全通報系統」的精神為「無懲罰」、「保密」及「匿名」，鼓勵「自願」通報及「互相學習」，但因輸血相關事件定義沒有共識及對血庫發血後至床邊掛血階段無法掌控，造成通報率偏低，本院的經驗或可提供參考。 The“Taiwan Patient Safety Reporting System (TPR)” was implemented in 2004, of which the rate of transfusion incident reporting was between 0.5% and 1.8%. This paper was an observation study and conducted at Kaohsiung Veterans General Hospital in two phases. Phase 1 was from October1996 to December 2003 and phase 2 was from January 2004 to March 2007.The transfusion incidents report form was adopted from hospital medical incident report form and redesigned according to the ISO 15189, which included 43 items of pre-examination, examination and post-examination procedures. A total of 73 transfusion incidents were reported, of which phase 1 was 38 and phase 2 was 35. In phase 1, all incidents were discovered in blood bank and by medical technologists, and belonged to pre-examination procedure, of which 92.1% caused by wrong samples. In phase 2, nurses reported 51.4% of incidents outside blood bank, of which 62.9% belonged to post-examination procedure and chiefly concerned about the quality of blood components. Two occasions of ABO incompatible hemolytic transfusion reaction were identified in phase 2 and underwent root cause analysis. Most of the causes of the incidents were due to systemic factors (76.9%) and belonged to near-miss errors (52.6%). The implementation of formal process definitions will encourage our clinical colleagues to overcome the under -reporting rate.

The“Taiwan Patient Safety Reporting System (TPR)” was implemented in 2004, of which the rate of transfusion incident reporting was between 0.5% and 1.8%. This paper was an observation study and conducted at Kaohsiung Veterans General Hospital in two phases. Phase 1 was from October1996 to December 2003 and phase 2 was from January 2004 to March 2007.The transfusion incidents report form was adopted from hospital medical incident report form and redesigned according to the ISO 15189, which included 43 items of pre-examination, examination and post-examination procedures. A total of 73 transfusion incidents were reported, of which phase 1 was 38 and phase 2 was 35. In phase 1, all incidents were discovered in blood bank and by medical technologists, and belonged to pre-examination procedure, of which 92.1% caused by wrong samples. In phase 2, nurses reported 51.4% of incidents outside blood bank, of which 62.9% belonged to post-examination procedure and chiefly concerned about the quality of blood components. Two occasions of ABO incompatible hemolytic transfusion reaction were identified in phase 2 and underwent root cause analysis. Most of the causes of the incidents were due to systemic factors (76.9%) and belonged to near-miss errors (52.6%). The implementation of formal process definitions will encourage our clinical colleagues to overcome the under -reporting rate.