An Audit on Near-Miss Events in Transfusion Medicine: The Experience of the Teaching Hospital in Northeastern Malaysia

The rate of near misses in transfusion is important as it indicates situations with the potential of adverse outcome. The aim of this study was to assess the frequency of mislabeled and miscollected samples received by our transfusion medicine unit. This study was conducted from January to December 2009 in Transfusion Medicine Unit, Hospital Universiti Sains Malaysia. The total number of near-miss events reported and analysed over the 1-year period was 178 (0.40%). All mislabeled and miscollected samples and its location cases were identified. Mislabeled and miscollected (WBIT) samples were 66.3% and 33.7%, respectively. The highest number of mislabeled and miscollected samples was from accident and emergency unit and medical ward, respectively. Continuous monitoring and analysis of near misses data should be mandatory in order to improve the safety of transfusion. 1. Introduction Hospital Universiti Sains Malaysia is a teaching hospital in northeastern Malaysia with a total of 800 beds. The services that are offered by the transfusion medicine laboratory range from routine immunohematology, that is, ABO and Rh grouping, group screen and hold, group cross match, antibody titre and direct Coombs test, to special tests that is, red cell antibody identification, platelet antibody screening, cold agglutinin test, Donath Leinsteiner test, and so forth. We also provide peripheral stem cell collection and preparation for the haemato-oncology unit in the hospital. The laboratory is run by 6 medical technologists, 3 senior medical technologists, 1 scientific officer, and 2 haematologists. Most errors result from human actions. Hence, the errors may be preventable, and hospital-wide efforts at prevention are required [1]. Safety and reliability in blood transfusion are not static are dynamic nonevents. Collection of the patient’s sample for pretransfusion testing initiates a complex chain of events in the transfusion process [2]. Half of the reported serious adverse events from transfusion are consequences of medical errors. The greatest risk in transfusion medicine is actually human error, resulting in the use of the incorrect blood component [3]. Mislabeled sample is defined as that not meeting local standards for sample acceptance. Miscollected sample is defined as sample in which the ABO or D type of the blood in the tube is different from the result already in the record for the patient’s name on the tube with the exception of change in blood type due to bone marrow transplantation [4]. A major cause of ABO-incompatible transfusion is the “wrong blood in