Surveillance of blood in Norway 2010. TROLL. Adverse outcomes of transfusion
Report
|Updated
One patient was infected with hepatitis C virus by transfusion. This is the first case of hepatitis C transmission in Norway since the haemovigilance system was launched in 2004.
Key message
The Norwegian Knowledge Centre for the Health Services runs the Norwegian Haemovigilance System on behalf of the Norwegian Directorate of Health. One of our tasks is to publish an annual report. The purpose of this report is to form the knowledge basis for the continuous improvement of the transfusion services. This 2010 report is divided into sub reports. This sub report is about adverse outcomes of blood transfusion. Background and method are described in a separate report (to be published).
Nearly 265 000 transfusions were performed in Norway in 2010, 196 883 red blood cell transfusions, 22 977 platelet transfusions and 45 085 plasma (Octaplas®) transfusions. We received 183 reports on adverse outcomes (69 per 100 000 transfusions). Mild allergic reactions were the most frequently reported reactions (25 per 100 000 transfusions), followed by febrile non-haemolytic reactions (15 per 100 000 transfusions). Approximately 16 % of the adverse outcomes were reported as serious (11 per 100 000 transfusions).
Sex ratios seem to reflect sex ratios among transfused patients. Adverse effects seem to be more frequent among children than among adults, probably due to a predominance of allergic reactions among children. Unfortunately, we lack reliable background data on transfused patients in Norway.
Nineteen incidents of incorrect blood component transfused (IBCT) were reported, five incidents of blood component intended for another patient, 13 incidents of failure to provide blood components of the appropriate specification and one incident of blood transfused in the wrong indication due to errors in sampling. Three cases of serious haemolytic transfusion reaction were reported, two due to ABO incompatibility and one due to anti-Jk(b). In all the IBCT cases the bedside control routines were not followed. Failure to provide blood component of the appropriate specification was most often caused by errors in the selection and delivery of blood from the blood bank, sometimes by errors with the order.
Seven incidents of haemolytic transfusion reaction caused by non ABO antibodies were reported, four acute and three delayed reactions.
One patient was infected with hepatitis C virus by transfusion. This is the first case of hepatitis C transmission in Norway since the haemovigilance system was launched in 2004. One case of transmission of white staphylococci from platelet concentrate was also reported. This is the first confirmed case of bacterial transmission since the reporting system started.
Six anaphylactic reactions were reported, one case of TRALI, and two cases of haemolysis caused by too high temperature in blood warmer devices. As in previous years, no case of transfusion associated graft-versus-host disease or posttransfusjonspurpura has been reported.
For discussion, conclusions and recommendations, see the other sub reports (to be published).