Delving into transfusion safety?

The guiding principle of transfusion is safe, appropriate, efficient, effective, and timely use of blood and blood products. To do this requires a complex, multi-step process which unfortunately provides many opportunities for error which in worst cases can be fatal. Therefore good system design is essential in making transfusion safe.

What we know about transfusion safety is very much due to the efforts of haemovigilance programs such as the UK’s ‘Serious Hazards of Transfusion’ (SHOT) scheme and here in Australia the National Blood Authority’s ‘National Haemovigilance Program’ and Victoria’s Blood Matters ‘Serious Transfusion Incident Reporting’ (STIR) system. Haemovigilance programs can be thought of as “patient safety monitoring” programs and provide a barometer to the health of the transfusion system, and where, when, and how things are going wrong.

The SHOT scheme is undoubtedly the world’s best known haemovigilance scheme. The July release of the SHOT report [1] is a highly anticipated annual event. As in previous years the recently released 2022 report is essential reading for anyone involved in transfusion, providing a detailed and revealing insight into transfusion-related adverse events. It can take a while to fully digest the report’s 261 pages but amply rewards the effort. Furthermore, the SHOT website contains a plethora of useful resources and publications intended to inform and aid improvements in transfusion practice. Although the SHOT report relates to haemovigilance in the UK most, if not all, of the lessons arising out of the report are universally applicable.

Events arising from errors continue to comprise the majority of reports to SHOT. These types of events are entirely preventable, but unfortunately this figure remains consistently high (over 80%) year to year. Thankfully, most of these events are near misses where the process breakdown was detected before transfusion and therefore before potential harm could occur. Near misses are often overlooked but provide a spotlight on where the system is not performing as it should.

When investigating adverse events involving errors it is tempting and easy to blame the individual/s involved. While events due to “human error” cannot be overlooked it is important to remember in a just and learning culture that staff should not be the scapegoats for systemic problems. SHOT has been leading the way in incorporating human factors and ergonomic (HFE) analysis in haemovigilance reporting to assist our understanding of the underlying causes behind adverse events.

Haemovigilance should not be about simply collecting data, and as the SHOT report and the schemes associated activities exemplify the importance and benefit to widely communicating findings, lessons learned and necessary systemic or practice improvements.

Reference

1.   S Narayan (Ed) D Poles et al. on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group. The 2022 Annual SHOT Report (2023). https://doi.org/10.57911/wz85-3885