Surveillance of blood in Norway 2012. Near misses
Report
|Updated
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.
Key message
Background
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.Near misses are reported by the blood bank electronically on www.hemovigilans.no.
Results
- In 2012 we received 91 reports on near misses, 43 per 100 000 donations.
- In 40 cases blood that did not fulfill the appropriate specification were transfused. In 26 of these cases there were errors in the donor selection.
- In total, 36 near misses were related to donor selection.
- Fourteen near misses were related to wrong labelling of samples and one were wrong labelling of a blood bag.
- There were twelve reports about analytic errors.
- Human error was the main cause of 47 near misses.
Discussion
Donor selection and wrong labelling are well known problems in the transfusion service.
In 2012 we also received reports related to analysing blood samples including reports of reagents not fullfilling our quality requirements.
In most cases where blood not fullfilling our quality criteria was transfused, it is possible in retrospect to state that no harm could have been caused, eg because donors were tested for infectious agents at a later donation.