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      Prevalence of Near-miss Events of Transfusion Practice and Its Associated Factors amongst House Officers in a Teaching Hospital

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          Abstract

          Objectives

          A near miss in transfusion practice is defined as a deviation from standard procedures discovered before transfusion and can lead to a transfusion error. Information on near-miss events provides pivotal data on areas of improvement to prevent actual errors in the future. Our study sought to determine the prevalence and rate of near-miss events and their associated factors amongst house officers (HO) in Hospital Universiti Sains Malaysia.

          Methods

          The initial part of this study is a descriptive cross-sectional study involving data collection from all requests sent for group, screen, and hold (GSH) and group and cross match (GXM) tests from 2011 to 2017. The association between sociodemographic, workplace, and experience factors with near-miss events amongst HO was analyzed with a case-control study using logistic regression.

          Results

          We reported 83 near-miss events with a prevalence of 0.034% (95% confidence interval 0.027–0.042). The rate of near-miss events was one in every 2916 requests. The mean reporting rate was 11.9 events per year. Clinical near miss predominated at 89.2% compared to 10.8% laboratory near miss. Mislabeled events (33.7%) were more than miscollected events (10.8%). HO were implicated with most events (83.1%). Most events were predominantly in the medical and obstetrics and gynecology wards amounting to 31.3% each. We found a significant association between the ages of HO with near-miss events.

          Conclusions

          The prevalence of near-miss events in our hospital was relatively low. Our study has shown areas for improvement include improving sampling practices in clinical areas, adequate training of laboratory technicians, and providing proper transfusion education. Interventions such as encouraging compliance to guidelines and training in clinical and laboratory areas to minimize the risk of mistransfusion should be considered.

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          Most cited references36

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          Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety

          Summary The Serious Hazards of Transfusion (SHOT) UK confidential haemovigilance reporting scheme began in 1996. Over the 16 years of reporting, the evidence gathered has prompted changes in transfusion practice from the selection and management of donors to changes in hospital practice, particularly better education and training. However, half or more reports relate to errors in the transfusion process despite the introduction of several measures to improve practice. Transfusion in the UK is very safe: 2·9 million components were issued in 2012, and very few deaths are related to transfusion. The risk of death from transfusion as estimated from SHOT data in 2012 is 1 in 322 580 components issued and for major morbidity, 1 in 21 413 components issued; the risk of transfusion-transmitted infection is much lower. Acute transfusion reactions and transfusion-associated circulatory overload carry the highest risk for morbidity and death. The high rate of participation in SHOT by National Health Service organizations, 99·5%, is encouraging. Despite the very useful information gained about transfusion reactions, the main risks remain human factors. The recommendations on reduction of errors through a ‘back to basics’ approach from the first annual SHOT report remain absolutely relevant today.
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            Guidelines for pre-transfusion compatibility procedures in blood transfusion laboratories. British Committee for Standards in Haematology.

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              Prevalence of Pre-Analytical Errors in Clinical Chemistry Diagnostic Labs in Sulaimani City of Iraqi Kurdistan

              Background Laboratory testing is roughly divided into three phases: a pre-analytical phase, an analytical phase and a post-analytical phase. Most analytical errors have been attributed to the analytical phase. However, recent studies have shown that up to 70% of analytical errors reflect the pre-analytical phase. The pre-analytical phase comprises all processes from the time a laboratory request is made by a physician until the specimen is analyzed at the lab. Generally, the pre-analytical phase includes patient preparation, specimen transportation, specimen collection and storage. In the present study, we report the first comprehensive assessment of the frequency and types of pre-analytical errors at the Sulaimani diagnostic labs in Iraqi Kurdistan. Materials and Methods Over 2 months, 5500 venous blood samples were observed in 10 public diagnostic labs of Sulaimani City. The percentages of rejected samples and types of sample inappropriateness were evaluated. The percentage of each of the following pre-analytical errors were recorded: delay in sample transportation, clotted samples, expired reagents, hemolyzed samples, samples not on ice, incorrect sample identification, insufficient sample, tube broken in centrifuge, request procedure errors, sample mix-ups, communication conflicts, misinterpreted orders, lipemic samples, contaminated samples and missed physician’s request orders. The difference between the relative frequencies of errors observed in the hospitals considered was tested using a proportional Z test. In particular, the survey aimed to discover whether analytical errors were recorded and examine the types of platforms used in the selected diagnostic labs. Results The analysis showed a high prevalence of improper sample handling during the pre-analytical phase. In appropriate samples, the percentage error was as high as 39%. The major reasons for rejection were hemolyzed samples (9%), incorrect sample identification (8%) and clotted samples (6%). Most quality control schemes at Sulaimani hospitals focus only on the analytical phase, and none of the pre-analytical errors were recorded. Interestingly, none of the labs were internationally accredited; therefore, corrective actions are needed at these hospitals to ensure better health outcomes. Internal and External Quality Assessment Schemes (EQAS) for the pre-analytical phase at Sulaimani clinical laboratories should be implemented at public hospitals. Furthermore, lab personnel, particularly phlebotomists, need continuous training on the importance of sample quality to obtain accurate test results.
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                Author and article information

                Journal
                Oman Med J
                Oman Med J
                OMJ
                Oman Medical Journal
                OMJ
                1999-768X
                2070-5204
                31 March 2021
                March 2021
                : 36
                : 2
                : e249
                Affiliations
                [1 ]School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
                [2 ]Transfusion Medicine Unit, Hospital Universiti Sains Malaysia, Kelantan, Malaysia
                Author notes
                [* ]Corresponding author: drhaslina@ 123456usm.my
                Article
                OMJ-36-02-2000100
                10.5001/omj.2021.55
                8053256
                33898061
                276b2c97-b4ad-4344-b3f2-b82962e8bfc7
                The OMJ is Published Bimonthly and Copyrighted 2021 by the OMSB.

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial (CC BY-NC) 4.0 License. http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 18 May 2020
                : 26 August 2020
                Categories
                Oiginal Article
                Oiginal Article

                cross-sectional studies,near miss, healthcare,blood transfusion,hospitals, teaching

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