Many improvements in blood safety have rightfully focused on reducing the risks of blood transfusion that are donor-associated, namely reducing the risk of transfusion transmitted infection and the risk of transfusion related acute lung injury. To that end Hemovigilance systems collect transfusion reaction data that serves to validate national or regional changes in blood collection, manufacturing, and testing to make blood products safer than ever. An under-recognized area of the Hemovigilance systems is the collection of errors and incidents associated with identification, selection, storage, and administration of blood products at the hospital level. While reported events may not culminate in harms reaching case-specific patients, they reflect conditions that are conducive to injuries as significant as mis-transfusion or circulatory overload. Hospitals may be limiting in their power to mitigate reactions related to external, upstream factors, but they have opportunities to identify and rectify process errors culminating in harm.
Review the National Healthcare Safety Network (NHSN) classification scheme for reporting errors or incidents.
Review the pattern of reported errors or incidents at the national and local level.
Assess examples of error-reduction initiatives initiated based on use of review of local errors/incidents data.