Overvåking av blod i Norge. TROLL. Blodtransfusjonstjenesten i Norge. Delrapport 5. Andre uønskede hendelser
Report
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Summary
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 near misses.
The Norwegian Haemovigilance System was voluntary and anonymous from 2004 until 2007, when new legislation made it compulsory. The transition from voluntary to compulsory system was smooth. In 2007 reports of near misses were included in the system.
Materials and methods
Near misses are reported by the blood bank electronically on www.hemovigilans.no.
Results
In 2010 we received 101 reports on near misses, 46 near misses per 100 000 donations. In 43 cases blood that did not fulfill the appropriate specification were transfused. In 24 of these cases there were errors in the donor selection. In total, 42 near misses were related to donor selection. Twenty-two near misses were related to equipment failure, mainly scales and sealers. Human error was the main cause of 45 near misses. In 19 of these donors were accepted, despite not fulfilling the donor criteria. Seven reports were about wrong labelling and five about analytic errors.
Discussion
Human error is reported as the main cause of 45 near misses. Since to err is human, we should focus on improving the systems and add the necessary barriers to prevent human errors from harming the patients. A large number of reports are about donor selection. This indicates that correct donor selection is difficult and that the training of staff in donor selection needs to be improved.