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About this publication
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 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.
In 2011 we received 121 reports on near misses, 55 near misses per 100 000 donations. In 63 cases blood that did not fulfill the appropriate specification were transfused. In 46 of these cases there were errors in the donor selection. In total, 55 near misses were related to donor selection. Twenty-six near misses were related to wrong labelling.
Human error was the main cause of 60 near misses. In 15 of these donors were accepted, despite not fulfilling the donor criteria. Eight reports were about analytic errors. Twenty-one reports are about incorrect labelling of blood samples. In 51 near misses the primary cause were classified as other causes. Twenty-three of these are related to donor selection and 14 is information given by the donor after donation.
Human error is reported as the main cause of 60 near misses. Many of these are mistakes during donor selection and during labelling of blood samples. 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. To a certain extent we succeed in building effective barriers. One example is the requirement of blood typing in two different samples taken at different times. 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.